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What Are the Major Diseases Involving Copper Metabolism?

PediatricEducation.org — Mon, 06 Feb 2012 00:08:49 +0100

Discussion Nutritional problems can occur in all parts of the world and in all socioeconomic strata. Caloric and/or protein inadequacy unfortunately plagues too many people because of inadequate supplies or availability. Supplemental food programs around the world attempt to provide appropriate nutrition, but can be stymied because of war, political instability, economic instability and many other social factors. The most common specific nutrient deficiencies are iron and Vitamin D deficiencies. Minerals important for essential nutrition include copper, iodine, selenium and zinc. A typical mixed diet usually provides enough minerals. In the United States, mineral deficiencies are usually uncommon unless there is an underlying disease process or abnormal food restrictions or diet. Vegan an...

What is the Mnemonic for the Elbow Ossification Centers?

PediatricEducation.org — Mon, 30 Jan 2012 00:11:02 +0100

Discussion Injuries to the pediatric elbow are difficult to diagnose because of the anatomy and normal growth and ossification of the elbow. Swelling, tenderness, ecchymosis, with or without deformity are common signs of fracture. Physical examination should include a careful neurovascular examination for distal pulses and capillary refill, paresthesias, increased pain with movement distal to the elbow or paralysis of the hand muscles as any of these may indicate compartment syndrome. Common radiographs obtained are AP and lateral plain radiographs. Oblique films and comparison films of the contralateral elbow are also often needed to distinguish between a fracture and normal growth plate. The alignment of the anterior humerus line and the fat pads should be reviewed as misalignment may ...

What Can Parents Do To Keep Their Children Safe on Playgrounds?

PediatricEducation.org — Mon, 23 Jan 2012 00:50:28 +0100

Discussion About 200,000 children are injured each year on playgrounds costing an estimated 1.2 billion dollars. Most of the playground injuries are at schools and daycare centers and gender rates and age rates depend on the study. More injuries occur in the summer months. Rates of severe injuries varies depending on classification and the specific study conducted. Fractures, lacerations, contusion/abrasion, and strains/sprains all are common injuries. Falls contribute to about 80% of injuries. Between 1990-2000, 147 children died from playground injuries – 82 from strangulation and 31 from falls. The number decreased from 2001-2008 to 40 deaths with 27 due to strangulation and 7 due to head injury. Climbing equipment and swings cause the most equipment-related injures. Learning Poin...

How Can You Stop A Habit?

PediatricEducation.org — Mon, 16 Jan 2012 00:30:18 +0100

Discussion In 1973, Azrin and Nunn published the first paper on habit reversal. Their 12 patients (ages 5-64 years) had immediate improvement in a variety of problems including nail-biting, thumb-sucking, hair pulling and tic behaviors. Others have built upon their methods and shown efficacy in a number of habits including tics, stuttering, hair pulling, skin picking, nail biting, finger sucking, etc. Habits can be automatic or focused. Automatic being that the habit occurs when the patient is not aware (e.g. studying, sitting in a car, etc.). Patients are not aware of the habit until sometime later or the episode is complete (e.g. nail is ripped off). Focused is when there is a awareness of the episode, but the patient does the habit anyways. As patients need some cognitive awarness to ...

When Is More Treatment Needed for Infantile Hemangiomas?

PediatricEducation.org — Mon, 09 Jan 2012 00:30:57 +0100

Discussion Infantile hemangiomas (IH) are the most common soft tissue tumors in infants. They are usually considered birthmarks but are dynamic lesions. They usually begin in the first few weeks of life and rapidly grow in the first 3-5 months of life. By 5 months, most lesions will have achieved 80% of their final size. Almost all IH have cessation of growth after 9 month of age. Images of IH can be seen in the To Learn More section below. Learning Point Often no treatment is necessary for IH other than expectant monitoring. Additional treatment may be necessary depending on the patient’s age, lesion type, location, size and complication being considered. The results of a prospective cohort of 1058 children in 7 pediatric dermatology clinics found that overall 24% of patients had c...

Happy Holidays!

PediatricEducation.org — Mon, 26 Dec 2011 00:06:42 +0100

Thank you for being loyal Pediatric Education users. We’re taking a short break and will be back January 9th with our next case. Our best wishes to you in the New Year. Donna D’Alessandro and Michael D’Alessandro, Curators. (Source: PediatricEducation.org)

What Causes a Black Colored Tongue?

PediatricEducation.org — Mon, 19 Dec 2011 00:29:33 +0100

Discussion Although dental caries, strep throat and oral candidiasis are some of the most common oral pathology. The tongue itself can be a source of potential pathology. Geographic tongue, oral candidiasis, and lingual ulcerations are common problems. Most discolorations of the tongue are because of food, drink or medications that are ingested and are self-limited. However discoloration can be a sign of more significant problems. Hairy tongue, often colored black, is a relatively uncommon problem in the US but has a higher incidence reported in Turkey and Iran. It is more common in adults than children but has been reported in a child 2 months of age. It is also called lingua villosa nigra and is a benign condition caused by keratin accumulation usually in the setting of poor oral hygiene...

Who Was Virginia Apgar and How Good is Her Scoring System?

PediatricEducation.org — Mon, 12 Dec 2011 00:17:38 +0100

Discussion Dr. Virginia Apgar was the first woman at Columbia University College of Physicians and Surgeons to hold a full professorship. She was also the Chairman of the Department of Anesthesia and was interested in obstetrical anesthesia and newborn resuscitation. Although it is unclear how she developed the “Apgar score,” a peer of hers says she began to be upset at the lack of resuscitation and treatment efforts for “…apneic, small for age or malformed newborns…[She]began to resuscitate these infants and to develop a scoring system that would ensure observation and documentation of the true condition of each newborn during the first minute of life.” The first minute was used because clinical depression is often maximal at this time. Pictures and a f...

When Do You Start Children on Lipid Lowering Medications?

PediatricEducation.org — Mon, 05 Dec 2011 00:16:20 +0100

Discussion Research has supported the idea of childhood precursors to adult disease including obesity and for cardiovascular disease. Cardiovascular disease is the leading cause of morbidity and death in the United States and dyslipidemias are one risk cardiovascular disease. Dyslipidemias do occur in childhood. Despite much research, there is still more that remains to determine the exact laboratory cut off numbers for various treatments and the best pharmacological treatments for patients that might benefit from them. The American Academy of Pediatrics (AAP) recommends that all children eat a healthy diet, and for those with risk factors (i.e. family history of hyperlipidemia, premature cardiovascular disease, obesity, hypertension, diabetes mellitus, cigarette smoking or an unknown fami...

How Do You Treat Thumb Injuries?

PediatricEducation.org — Mon, 28 Nov 2011 00:14:50 +0100

Discussion The thumb has two phalanges anda metacarpal and articulates with the trapezium bone in the wrist. It gives humans prehensile abilities. Children can be difficult to examine because of their developmental age including non-compliance, fear and ability to understand. Pain also does not help the examination. Pain, decreased range of motion and swelling along with abnormal position may indicate a fracture or dislocation. Crepitus and abnormal skin findings such as dimpling, and a filled in normal crease may indicate a more serious problem. Almost all injuries are treatable by immobilization and as necessary surgical treatment with open reduction and possible fixation. If there is doubt about the treatment, a referral should be made to the appropriate local resource such as an ortho...

What Do You Do When The Parent is Impaired?

PediatricEducation.org — Mon, 21 Nov 2011 00:47:49 +0100

Discussion Workplace violence is defined by the Occupational Health and Safety Administration (OSHA) as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.” Social services and health care professionals are at high risk for workplace violence, with the numbers probably higher because of underreporting. In 2000 the Bureau of Labor statistics reported the following rates of injuries from violent acts and assaults. Rates are per 10,000 full-time workers Overall private sector 2 Health services 9.3 Social services 15 Personal care facility 25 The Department of Justice has average annual rates of non-fatal violent crime from 1993-1999. Rates are per 1000 workers All occupations 12.6 Physicians 16.2 Nurse...

How Good Are Hearing and Vision Screening Tests in Children?

PediatricEducation.org — Mon, 14 Nov 2011 00:28:22 +0100

Discussion Sensory problems in children like any problem should try to be identified as early as possible so effective treatment plans can be carried out. Hearing About 1-4 children/1000 newborn infants have hearing loss or about 8-16,000 infants/year in the US. Before universal hearing screening the average age for detection was 2 1/2 -3 years of age. In 2010, an evaluation of the universal newborn hearing screening programs found that about 92% of infants were screened before discharge with 4% failing the before discharge screening. Unfortanately only 2% were referred for a diagnostic evaluation. The authors cite multiple barriers to universal screening and followup. Types of hearing testing for screening includes evolked otoacoustic emission testing, auditory brainstem response or bo...

What Can Cause Memory Problems?

PediatricEducation.org — Mon, 07 Nov 2011 00:29:23 +0100

Discussion Memory is the ability to recall prior experiences including visual, auditory and spatial relationships. Memory integrates experiences, thoughts and impressions together. It is an important component of executive functioning and social interaction. Some definitions: Working memory – which lasts seconds, usually associated with rehearsal and use of information and is associated with prefrontal cortex and angular gyrus Episodic memory – which lasts minutes to years and is associated with the hippocampus and limbus Semantic memory – associated with factual information and is associated with the inferolateral temporal lobes Procedural memory – associated with performing a common task (e.g. brushing teeth, tying shoes, driving a car, etc.) and is associated ...

What Are Risk Factors for Grade Retention?

PediatricEducation.org — Mon, 31 Oct 2011 00:31:22 +0100

Discussion Grade retention is often an emotionally charged discussion and decision. Unfortunately there is not a comprehensive body of research literature to draw upon to make these important decisions. Grade retention is common and costly. An estimated 9.6% of student were retained at least once before 9th grade. One estimate, in Texas in 2006-2007, had a yearly per student cost of $10,162 per retained student or over 2 billion dollars to the Texas school systems. Research has shown that: Children who are retained have poorer academic achievement than promoted peers After retention, the academic gains from the retained year fade after 2-3 years. Retention often is associated with increased behavior problems – particularly as they get older (i.e. junior high, high school and young a...

What Are Indications for IUD Use in Teens?

PediatricEducation.org — Mon, 24 Oct 2011 00:10:53 +0100

Discussion Intrauterine devices (IUDs) are inserted into the uterus to remain in place for usually 1-10 years. They prevent implantation or fertilization by releasing hormones (progestin) or ions (copper). They are very effective when used appropriately amd are up to 99% successful in preventing pregnancy and they are generally safe. Infection is one of the biggest risks which is why IUDs often are not recommended for adolescents who often are serially monogamous or have multiple partners thus increasing their risk of a STI. Liability is also a concern for an adolescent who may have future infertility problems and attribute them to the IUD use. IUDs do not affect fertility in the absence of an infection. Learning Point IUDs can be useful in patients who are consistently using STI preventio...

When Can Our Patient with Anorexia Go to the Psychiatry Unit?

PediatricEducation.org — Mon, 17 Oct 2011 00:49:23 +0100

Discussion Patients with anorexia nervosa refuse to maintain their body weight at or above a minimally normal weight for age and height (basically less than 85% of expected). They have an intense fear of gaining weight or becoming fat, even though they are underweight. They also have a distorted view of their own body weight or shape and often deny the seriousness of being underweight. For women who are postmenarchal, amenorrhea often occurs. Anorexia nervosa can have numerous complications which can be reviewed in the To Learn More section below. Cardiovascular problems include vascular instability with orthostasis, bradycardia and poor perfusion. Conduction abnormalities and repolarization abnormalities are potentially life-threatening requiring aggressive management. Myocardial dysfunc...

When Should Children Begin Fasting?

PediatricEducation.org — Mon, 10 Oct 2011 00:39:55 +0100

Discussion Fasting means different things to different people. Usually it is refraining from eating and/or drinking for a period of time, or abstaining from certain foods or drinks. Fasting can be caused by physiology (i.e. sleeping), volitional (i.e. due to personal preferences, religious reasons, political protests, etc.) or non-volitional (i.e. pre-surgical fasting, lack of water or food availability, etc.). An energy source, especially for the brain, and fluid are necessary to maintain a healthy body. If someone is denying calories, after a few hours, glucose that is readily available from the digestive system is depleted. Gluconeongenesis then begins utilizing stores mainly within the liver (gluconeogenesis occurs for hours to days). If the fast continues, then protein is utilized fo...

When Can a Child Go Into A Pool?

PediatricEducation.org — Mon, 03 Oct 2011 00:54:30 +0100

Discussion Water safety is clearly important for all ages. Drowning was the second leading cause of unintentional injury death in US children from 1-19 years between 2000-2006. Non-fatal drowning victims usually do well, but 5-10% have severe neurological damage. The highest rate of drowning is in 0-4 year olds, with half of the drowning occurring in swimming pools. Infants < 1 year have a high rate of drowning in bathtubs and large buckets of water. To prevent drowning, experts generally recommend "layers of protection" including: Adult supervision – a designated adult supervisor who is not distracted by other activities such as sun bathing, reading, or talking with other adults Pool fencing – separate 4-sided fencing isolating the pool from other structures including a house...

What are the Clinical Differences Between Acute Paronychia and Herpetic Whitlow?

PediatricEducation.org — Mon, 26 Sep 2011 00:21:53 +0100

Discussion Primary herpes simplex virus (HSV) infection usually shows symptoms 2-20 days after contact. The virus enters the skin or mucous membranes and may then enter the dorsal root gangilons and become latent only to reactivate months to years in the future. Humans are the only known host. Recurrent infections may be caused by various stresses, including mental stress, fever, temperature extremes, sun or ultraviolet light exposure, trauma and immunosupression. HSV-1 usually causes gingivosomatitis and usually enters the trigeminal neuron. HSV-2 usually causes herpes genitalis and enters the sacral nerves. Primary oral HSV-1 usually has fever, with mouth lesions occurring and cervical and submandibular lymphadenopathy In primary oral HSV-1, symptoms may include a prodrome of fever, fol...

How Many Children Live with Their Grandparents?

PediatricEducation.org — Mon, 19 Sep 2011 00:20:51 +0100

Discussion Grandparents provide an important and unique role in children’s lives, providing continuity across generations. Grandparents often provide indirect (i.e.suprvising and interacting with the children along with other adults) and direct childcare (being the sole care provider). The childcare arrangements may be informal or formal. In addition to regular child safety issues in any home, grandparent homes need particular attention in a few areas. Medications need to be properly locked out of reach of the children. Walking aids and other mobility equipment should be moved out of the child’s play area if possible. Handrails and bars in bathrooms should be covered with soft material if children will be bathed there. Furniture which may have been used in the past should be ch...

Is His Penis Too Small?

PediatricEducation.org — Mon, 12 Sep 2011 00:56:05 +0100

Discussion Examination of the genitalia in both genders is an important part of a complete physical examination. For males, a small penis is defined by normative data (see below). A micropenis “… is defined as a stretched penile length of less than 2.5 standard deviations below the mean for age.” Many people will use the terms micropenis and microphallus interchangeably, but others will use the term micropenis to be a short penis but normally formed, and a microphallus to be a short phallus with an associated anomaly such as hypospadias. Causes of micropenis are usually genetic (i.e. Kleinfelter, Noonan, Prader-Willi syndromes, etc.) or endocrinological, particularly anywhere along the hypothalamic-pituitary-gonad axis. Testosterone biosynthesis (i.e. 17-beta hydrosyster...

What Causes Coughs?

PediatricEducation.org — Mon, 05 Sep 2011 00:22:52 +0100

Discussion “A cough is a voluntary or involuntary explosive expiration. After a deep inspiration, the glottis is closed and the expiratory muscles contract, compressing the lung and raising intrapulmonary pressure above the atmospheric pressure. The glottis then opens, and gas is expelled at a rapid rate.” Acute coughs are commonly due to upper respiratory tract diseases in children of all ages – often because of post-nasal rhinorrhea. Chronic coughs may be more difficult to determine the cause of and may require more investigation, consultation, and/or empiric trials of medication including radiographic imaging of chest or sinuses, spirotometry, sweat chloride, methacholine challenge, bronchoscopy, gastroscopy, immunodeficiency testing, etc. Children with congenital abn...

What Causes Increased Body Hair?

PediatricEducation.org — Mon, 29 Aug 2011 00:21:30 +0100

Discussion Body hair, including its amount and distribution, have cultural norms and social implications that vary according to the group and individual. There are entire industries which cater to removing hair in certain body parts (i.e. underarms and legs for western women) and adding hair in other locations (i.e. head for western men). Excessive body hair (relatively) is usually often due to normal physiologic process (such as puberty) or genetic. Two definitions which are often confused are: Hypertrichosis – excessive, non-androgen induced hair growth in a localized or generalized pattern distribution in males or females. Hirsuitism – excessive, androgen-induced hair growth in a male pattern distribution in children and women. Learning Point The differential diagnosis of ...

What Causes Pediatric Stroke?

PediatricEducation.org — Mon, 22 Aug 2011 00:55:33 +0100

Discussion Stroke is “…the sudden occlusion or rupture of cerebral arteries or veins resulting in focal cerebral damage and clinical neurological deficits that persist for longer than 24 hours. Stroke can be ischemic, hemorrhagic or both.” Pediatric stroke, especially in a seemingly well child, is uncommon, but not as uncommon as often presumed. Outside the perinatal time period, the rate is 2-13 events /100,000 children/year or about the same rate as pediatric brain tumors. It unfortunately is also common cause of morbidity (75% of survivors have neurological deficits) and death (one of the 10 most common causes). Pediatric stroke presentations includes dystonia, emesis, fever, headache, hemiparesis, irritability, lethargy, and seizures. Adult stroke is often due to arte...

What Causes Ptosis?

PediatricEducation.org — Mon, 15 Aug 2011 00:13:37 +0100

Discussion Ptosis or blepharoptosis is the downward displacement of the upper eyelid. The eyelid aponeurosis, levator muscle and Muller muscle retain the proper position of the upper eyelid. Ptosis can be congenital or acquired. Some causes require immediate attention by an ophthalmologist for proper treatment to preserve eyesight including trauma, uveitis, orbital cellulitis, etc.. Other causes require additional subspecialty assistance such as a cerebrovascular accident, thyroid disease, myasthenia gravis, etc. Mild ptosis can be a cosmetic problem, but proper function and position of the eyelid is essential to preserve eyesight. Ptosis may decrease the amount of light entering the eye and therefore decrease acuity. Abnormal structural relationships of the globe and eyelid may cause sec...

Summer Posting Break

PediatricEducation.org — Mon, 01 Aug 2011 00:17:34 +0100

We’ll post our next cases on August 15, 2011. In the meantime, take a look at the Curriculum Maps on the right sidebar. (Source: PediatricEducation.org)

What Are the Indications for PET and PET/CT?

PediatricEducation.org — Mon, 25 Jul 2011 18:12:31 +0100

Discussion Positron emission tomography test (PET) and PET/CT that combines PET with computed tomography (CT) was first begun in the 1950s. In 2000 it was the TIME magazine invention of the year. PET gives functional, metabolic data about the human body. When combined with CT’s anatomical, structural data, PET/CT can give both data types concurrently. PET uses radioactive tracers linked to metabolites. One of the most common tracers is 18F-fluorodeoxyglucose (FDG), a glucose metabolite. Since FDG contains glucose, there will be background tracer uptake particularly in the skeletal muscle, brain, thymus, brown fat, heart, and gastrointestinal track. The tracer is excreted by the kidneys but not reabsorbed, so increased background may be seen in the urinary system. Increasing filtratio...

There are Bugs in the House!

PediatricEducation.org — Mon, 18 Jul 2011 00:42:23 +0100

Discussion Pests are just that: Pests. They are bothersome, annoying, and irritating. They can be dangerous or non-dangerous. Cockroaches are common insects that infest homes. Cockroach body parts and feces can be allergens for certain people. Cockroaches themselves do not directly infect humans with disease through saliva/blood etc., but they carry infectious organisms on their bodies. As cockroaches move in, around, along and through almost anything, they may transmit these organisms to humans through infected food and water, etc. that cockroaches have contacted. Cockroaches need food, water and shelter. They generally like carbohydrates so anything that is starch-based is roach food including any paper, wallpaper paste, envelope glue, and soap bars (which often contain carbohydrates). ...

What are the New Recommendations for Rabies Vaccine Treatment?

PediatricEducation.org — Mon, 11 Jul 2011 00:50:24 +0100

Discussion Rabies is an important zoonosis worldwide which causes progressive encephalomyelitis and a high fatality rate. About 55,000 people worldwide die annually. In the US, about 1-3 cases occur annually, but 20-30,000 people receive post-exposure prophylaxis (PEP) for rabies. Importantly, “PEP has never failed in the United States since the introduction of modern cell-derived vaccines in the 1970s.” Any mammal is susceptible to rabies virus. While domesticated dogs are an important reservoir internationally, in the US other terrestrial mammals are more important with geographical differences. The most important animals are coyotes, fox, raccoon, and skunk. Mongoose is also important in Puerto Rico. Bats are also important reservoirs. From 2000-2007, 17 of 20 rabies cases ...

How Effective Is Intralesional Candida Antigen for Treatment of Warts?

PediatricEducation.org — Mon, 04 Jul 2011 00:55:24 +0100

This study had a large dropout rate though (for warts 67% and for molluscum 47%). In another small study of 18 patients, 11 completed the study and 9 (82%) had complete resolution and 1 (9%)had partial resolution, with a median of 4 every 3-week injections. Also, 6 of 9 patients (67%) with additional warts at distant locations had resolution of those warts. Questions for Further Discussion 1. What is the cost of intralesional treatment with Candida antigen? 2. How effective is mumps or trichophytin antigen intralesional treatment of plantar warts? 3. How is intralesional candida antigen given? 4. How are plantar warts spread? Related Cases Disease: Warts | Human Papillomavirus Symptom/Presentation: Papulosquamous Lesions Specialty: Dermatology | Immunology | Infectious Diseases | Pharma...

What is the Risk of HIV Transmission from an Inanimate Object?

PediatricEducation.org — Mon, 27 Jun 2011 00:10:26 +0100

Discussion Blood-borne infections are always a risk for anyone. Some occupations pose higher risks than others such as health care workers, emergency responders, public safety personnel, sex-trade workers and body art professionals. These workers can be exposed to body fluids by sharps, mucous membrane and skin exposures. Personal safety equipment and universal precautions should be utilized properly, consistently every time there is the possibility of an exposure. Accidental exposures still occur and the CDC has recommendations for proper management and possible post-exposure prophylaxic medication use. The main concerns are for Hepatitis B, Hepatitis C and human immunodeficiency virus (HIV). Learning Point HIV basically cannot survive outside the human body for long. The main transmissio...

How Common Is An Incarcerated Umbilical Hernia?

PediatricEducation.org — Mon, 20 Jun 2011 00:05:31 +0100

Discussion Umbilical hernias are commonly seen in pediatric patients. They usually are markedly improved by 1 year of age, and should be gone by 4-5 years of age. Hernias at this time are often repaired for cosmesis and to decrease the risk of incarceration often in adulthood. Usually abdominal contents or fluid that lie within the hernia’s pouch are easily reduced with very minimal pressure. A review of umbilical masses can be found here. Incarcerated umbilical hernias are much more common in adults who have underlying reasons for increased abdominal presure including pregnancy, cirrhosis, abdominal transplantations, paracentesis, obesity and a variety of benign and malignant tumors. Learning Point Incarceration of umbilical hernias in children is uncommon to rare in the literature...

What Are Indications for Pelvic Examinations in Adolescents?

PediatricEducation.org — Mon, 13 Jun 2011 00:27:11 +0100

Discussion In 2010, the American College of Obstetricians and Gynecologists changed the recommendations for Papanicolaou (Pap) testing. The first Pap test is at 21 years of age regardless of the onset of sexual activity unless the patient has HIV or is immune suppressed and patients are then followed yearly after initiation of sexual activity. The reasons for this change are that although about 50% of high school students are sexually active, and about 50% of young women will have a positive test for human papilloma virus (HPV) within 36 months of initiating sexual activity, over 90% of the HPV infections will resolve within 24 months in patients with intact immune systems. HPV is the most common STI worldwide. Adolescent patients who have previously been screened and have cervical atypia...

Taking a Short Break

PediatricEducation.org — Mon, 30 May 2011 00:14:50 +0100

Our next post will be on June 13, 2011. So in the meantime, take a look at the Cases By … archives located on the right sidebar. (Source: PediatricEducation.org)

How Common Is Rheumatic Heart Disease?

PediatricEducation.org — Mon, 23 May 2011 00:38:38 +0100

Discussion Acute rheumatic fever (ARF) is a nonsupprative, auto-inflammatory response after group A streptococcus (GAS) that affects multiple organs, including the heart. Chronic heart effects, particularly of the mitral and other heart valves, is termed rheumatic heart disease (RHD). ARF is thought to be caused by an autoimmune phenomenon where antibodies to the GAS cross react with normal host antigens. About 60% of ARF patients develop RHD and this is correlated to the initial carditis’s severity. ARF symptoms can present 2-5 weeks after the GAS pharyngitis. Diagnosis of ARF includes 2 major, or 1 major and 2 minor Jones’ criteria in the clinical setting of a preceding GAS infection. The updated Jones’ criteria include: Major criteria Carditis – 30-45% of pati...

What Causes Vertigo in Children?

PediatricEducation.org — Mon, 16 May 2011 00:37:36 +0100

Discussion Dizziness is an abnormal sensation relative to position and space which is often vague. It includes imbalance, motion intolerance, light-headedness, unsteadiness, floating or tilting sensations. Dizziness can be caused by cardiovascular, CNS or systemic diseases. Vertigo is a subtype of dizziness that has a rotary or spinning sensation. Objects rotate around the patient or the patient rotates around the objects. Vertigo is usually categorized into peripheral or central causes. Central vertigo emanates from a CNS location, and may have other CNS symptoms such as headaches, aura, motor, sensory or visual symptoms such as tinnitis or hearing loss. Symptoms usually last longer and may increase in number, frequency or intensity. Peripheral vertigo emanates from a non-CNS location an...

When Can Children Use All-Terrain Vehicles?

PediatricEducation.org — Mon, 09 May 2011 00:01:44 +0100

Discussion All-terrain vehicles are 3- or 4- wheeled vehicles designed for one rider to be used in rough-terrain situations. They became available in the 1970s in the United States and because of severe instability, the 3-wheeled variety has not been manufactured since the 1980s. From 1997-2001, the overall exposure to ATVs increased by 36-50% depending on the variable studied and the injuries increased 104%. A 2005 study found 5292 children were hospitalized because of ATV-related injuries over 2 years with 1% dying and an additional 5% needing discharge to long-term care. Adolescent males had the highest risk of injuries and regionally those in the South and Midwest had the highest injury rates. The total hospital cost for the 2 years of hospitalizations was > $74 million. Another 2005 s...

What Advice Should I Offer About Summer Safety?

PediatricEducation.org — Mon, 02 May 2011 00:55:25 +0100

Discussion With the summer comes numerous opportunities for children and families to be outdoors and enjoy many recreational activities. Many of the activities are done each year such as grilling or bike riding, but some may be new and families need education to stay safe and have a good time. The heat and sun also provide additional challenges, but usually with attention and care should not interfere with summertime pleasures. Seasonal safety information for winter can be found here. Learning Point Below are some of the anticipatory guidance that can be offered to parents about summer safety. Prevention Taking breaks Children and adults may tire more quickly after playing or doing other outdoor activities. Take frequent breaks. Have something to drink and cool down. These simple steps...

What is the Difference between Nystagmus and Ocular Motor Apraxia?

PediatricEducation.org — Mon, 25 Apr 2011 00:14:04 +0100

Discussion Clinically, positive motor signs such as hypertonia, chorea, tics, and tremor are often easily to elicit. But negative neurological signs are more difficult to elicit and quantify. These include: Weakness – “…the inability to generate normal voluntary force in a muscle or normal voluntary torque about a joint.” Weakness is usually present in many different postures, movements or tasks, but could be only seen in certain ones. Spinal muscle atrophy is one example. Reduced selective motor control – “…impaired ability to isolate the activation of muscles in a selected pattern in response to the demands of a voluntary posture or movement.” For example, a child with congenital mirror movements. Ataxia – “…inability to ...

How Common is Orbital Cellulitis?

PediatricEducation.org — Mon, 18 Apr 2011 00:19:33 +0100

Discussion Orbital cellulitis is a serious infection whose complications can include meningitis, intracranial abscess, cavernous sinus thrombosis, carotid artery occlusion and vision loss. Orbital cellulitis itself is usually a complication of rhinosinusitis particularly of the ethmoid sinuses but also trauma. Haemophilus influenza type B usually has been the prevalent causative organism with Staphlococcus aureus and viridins streptococcus also being common causes. The microbiology appears to be changing though. A 25-year study shows that although immunization against Haemophilus influenza type B and pneumococcus have decreased the cases of invasive infections such as meningitis, epiglottitis and bacteremia, immunization does not appear to decrease the cases of orbital cellulitis. Yet a re...

What Are the Indications for Anticoagulant Medication?

PediatricEducation.org — Mon, 11 Apr 2011 00:44:39 +0100

Discussion While more research is being conducted on anticoagulation therapy for children, much is still gleaned from adult research and pediatric-specific research is needed. The usual adult indications for such treatment such as myocardial infarction and stroke are uncommon in the pediatric population, while other indications such as Kawasaki disease are unknown in the adult population. Fortunately for children, thromboembolic events are much less common overall. Transient thrombocytosis is often seen in myelodysplastic conditions such as leukemia and usually does not cause thromboembolic events. Treatment of the underlying disease process such as leukemia or infection in the patient above normally resolves the thrombocytosis. Choice of medication depends on the underlying condition and...

Does Oppositional Defiant Disorder Abate?

PediatricEducation.org — Mon, 04 Apr 2011 00:35:32 +0100

Discussion Oppositional defiant disorder (ODD) is a disruptive behavior with elements of defiance, disobedience, negativism and hostility to authority. Depending on the classification system, ODD may be a precursor to, or subtype of conduct disorder as they both share characteristics. The DSM IV criteria can be found here. ODD can be diagnosed alone or is also associated with other disorders such as ADHD, depression, and anxiety. Children are often not diagnosed with ODD until school age, but data supports temperamental antecedents even in early infancy, including exhibiting extreme emotions and activity consistent with ODD but at an earlier developmental level. Learning Point Children with ODD may or may not have abatement of symptoms as they get older. One 5-year longitudinal study of ch...

What Contaminants Are Found On A Child Taken From a Meth Lab?

PediatricEducation.org — Mon, 28 Mar 2011 00:33:50 +0100

Discussion Methamphetamine is an illegal, man-made, powerful central nervous system drug that gives the user an intense pleasurable feeling that is longer lasting than cocaine which it is similar to. Methamphetamine is highly addictive when used by smoking, inhaling, injecting or being swallowed. Because of unregulated manufacturing, numerous known and unknown chemical contaminants are possible in the manufacturing environment. Areas of highest contamination are in the area of direct manufacturing and chemical discharge such as drains and soil, but other locations where the chemicals can be tracked into such as wall and floors can be contaminated. Clean-up involves properly trained and protected workers using hazardous materials procedures including removal and proper disposal of contamina...

What Do You Call That Again?

PediatricEducation.org — Mon, 21 Mar 2011 00:41:20 +0100

Discussion Because histamine reactions such as urticaria or angioedema are usually thought of as systemic problems, localized involvement of many different body parts is often not considered in the differential diagnosis. The location and often unusual presentation may cause the clinician to consider more worrisome causes and therefore appropriately begin more evaluation and workup. Additional information about localized angioedema can be found here. Penile edema can also be caused by frequent or vigorous intercourse, insect bites, generalized edema or vasculitis such as Henoch Schonlein Purpura, in addition to some of the other problems listed below. Learning Point Clinicians may often confuse the terminology of common penile problems. Phimosis is a normal or abnormal condition where th...

What Are the New Medicines Available for Head Lice?

PediatricEducation.org — Mon, 07 Mar 2011 00:33:12 +0100

Discussion Head lice (Pediculosis capitus) is a common problem for worldwide. Multiple treatments are available with mixed success because of the life cycle of the parasite, the parasites’ ability to be transmitted between objects and persons, and the difficulty to clean the environment to rid the infestation. A previous review of lice can be found here that contains descriptions of the organism, other treatments and instructions for environmental cleaning. Learning Point In 2009, Ulesfia® was approved by the FDA. It is a 5% benzyl alcohol lotion that suffocates the lice; it is not directly ovicidal. It is approved for infants and children older than 6 months of age to age 60 years. It cannot be used in infants less than 6 months because of the potential for neonatal gasping synd...

When Will I Know Which Hand She Will Use?

PediatricEducation.org — Mon, 28 Feb 2011 00:37:59 +0100

Discussion Most children and adults do develop a hand dominance. Right-handedness is more common (70-90%) than left-handedness (8-10%). In many western cultures, right-handedness was/is considered the “correct” or “right” hand to use, and left-handedness was unlucky, inauspicious or frankly evil. The word “sinister,” meaning left-sided, derives from various sources as early as the 15th century. There are numerous instances of left-handedness being associated with wickedness. For example, the devil is often portrayed as left-handed, and people throw salt over their left shoulder to ward off the evil spirits that dwell there. Many left-handed people report being able to use their right hand very well for certain tasks because of needing to adapt to tools ...

What Causes Rhabdomyolysis?

PediatricEducation.org — Mon, 21 Feb 2011 00:04:36 +0100

Discussion Rhabdomyolysis was first described in 1881, and in 1941 a case series of crush victims from the Battle of Britain described rhabdomyolysis and subsequent acute renal failure. Injury to the skeletal muscle that results in leakage of the intracellular content into the plasma defines rhabdomyolysis or literally the dissolution of the skeletal muscle. Causes of the initial injury are numerous (see below). Rhabdomyolysis in adults is classically described by muscle weakness, myalgia and dark urine. But this triad is not common in children. In a 2005 study of 210 children, 45% had myalgia, 38% had muscle weakness, and 3.6% had dark urine. Only 1 patient had all 3 symptoms. Other signs and symptoms include fever, nausea, emesis, abdominal tenderness and decreased reflexes. Laborator...

300th Case for PediatricEducation.org

PediatricEducation.org — Mon, 14 Feb 2011 00:57:53 +0100

We are pleased to announce that the case today is PediatricEducation.org’s 300th case! Over the past 6 years, we have tried to offer a breadth of cases, which have aggregated into this unstructured curriculum of pediatric topics that also closely parallels the structured curriculum of a pediatric residency, fellowship and continuing medical education programs. We appreciate your continued patronage. As always we are looking for suggestions for new cases, ideas to improve the digital library and we would also like to hear about how you are using the cases for self-education or teaching of students. Please send your comments to: http://www.pediatriceducation.org/sendcomments Respectfully yours, Donna M. D’Alessandro and Michael P. D’Alessandro Curators, PediatricEducati...

What Causes a Bulging Anterior Fontanelle?

PediatricEducation.org — Mon, 14 Feb 2011 00:47:53 +0100

Discussion Included in the physical examination of the young child is palpation of the head. The posterior fontanelle is usually 1-2 cm at birth and closes around 1-2 months of age. The anterior fontanelle is usually 4-6 cm in size at birth and closes at 4-26 months of age. The fontanelle should be palpated in the upright position, and usually it is slightly depressed relative to the bony rim. Therefore a fontanelle that is level with the rim, or bulging above the rim, are both considered abnormal. A child in a recumbent position will normally have a fontanelle that is level or above the bony rim because of differences in pressure recumbent. A sunken or depressed fontanelle is usually caused by dehydration. A more extensive discussion about fontanelles can be found here. Learning Point The...

What Diseases are Spread Directly by Rodents?

PediatricEducation.org — Mon, 07 Feb 2011 00:44:46 +0100

Discussion Hantavirus pulmonary syndrome is a rare but potentially deadly disease transmitted by rodents. It was first discovered in 1993 in the southwest United States. It is usually contracted through aerosolization of the urine and feces with respiratory inhalation. Incubation can be up to 1-6 weeks. The prodrome occurs at 3-7 days with fever, chills, myalgia, headache, emesis, diarrhea, dizziness and sometimes cough. Extensive bilateral interstitial pneumonia with pulmonary edema and pleural effusions occur along with severe myocardial depression and hypotension. Treatment includes critical care support with possible extracorporeal membrane oxygenation. Ribavirin and steroids have been used in experimental trials. Mortality unfortunately is about 30-40% Learning Point Rodent spread dis...

Is This Complex Regional Pain Syndrome?

PediatricEducation.org — Mon, 31 Jan 2011 00:06:05 +0100

Discussion Musculoskeletal problems are a significant percentage of primary care visits (~20%), with pain being a common feature. Pain is a normal noxious sensation that is protective, but which has complex neurophysiological underpinnings and may have psychosocial overlays. Chronic musculoskeletal pain in children often begins orthopedic, rheumatologic, and oncologic evaluations. Chronic pain without an obvious biological cause can be frustrating for patients and clinicians alike to evaluate and treat. Learning Point Complex regional pain syndrome (CRPS) was previously known as reflex sympathetic dystrophy. It is usually seen in adults, with women more commonly than men experiencing the problem. It is seen in children usually starting in the tween and teenage years. There are often family...

What are the Laws Regarding Teenage Contraception?

PediatricEducation.org — Mon, 24 Jan 2011 00:16:53 +0100

Discussion Teenage pregnancy has decreased in recent years but the United States still has one of the highest rates in the world. Education is imperative so children, teens and adults understand the risks of early initiation of sexual intercourse, contraception, sexually transmitted infection prevention and treatment and adolescent gender issues. Confidentiality for seeking care and treatment is imperative for teens. While family relationships, health care providers and programs that promote and support abstinence and later initiation of sexual activity are extremely important, a high number of pre-teens and teens initiate sexual activity in the pre-teen and teen years. Therefore, confidentiality to seek sexual health care is important. “Sixty percent of teens younger than 18 who use...

What is the Dose of Light Therapy for Seasonal Affective Disorder?

PediatricEducation.org — Mon, 17 Jan 2011 00:19:22 +0100

Discussion Seasonal affective disorder was first systematically described in 1984. It can occur at different times of the year but predominantly winter and less commonly summer. The DSM IV criteria includes: There is a temporal relationship between the onset of major depressive episodes and a particular time of year. Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of year. In the last two years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined in the two criteria above and no nonseasonal major depressive episodes have occurred during the same period. Seasonal major depressive episodes substantially outnumber the nonseasonal major depressive episodes that may have occurred over t...

What Methods Can Be Used to Reduce Radial Head Subluxation?

PediatricEducation.org — Mon, 10 Jan 2011 00:35:18 +0100

Discussion Radial head subluxation commonly occurs in infants and toddlers because of the anatomy and child development. The radius is connected to the ulna just distal to the radial head by an annular ligament that encircles the radius “neck” (i.e. radial diaphysis) and inserts into the ulnar tuberosity. However the annular ligament is relatively small and also not as fibrous in young children compared to older children and adults. Young children often have their arm extended upward to hold hands with an adult especially when they are new walkers. If the child stumbles or for some other reason has the adult place traction (i.e. pull the extended arm) on the arm, the radial head can be subluxed distally and become entrapped in the ligament. This gives rise to the common name of...

What Parental Guidance Should I Offer to Parents About Winter Safety?

PediatricEducation.org — Mon, 03 Jan 2011 00:21:53 +0100

Discussion With the winter comes new challenges for children and parents to keep healthy and prevent problems while still getting outside and remaining active. Even those who don’t usually live in northern climates may still have seasonal storms that can bring ice and cold. People may visit family, friends or take a trip to a winter environment and need to learn or remind themselves how to stay healthy. Learning Point Below are some of the anticipatory guidance that can be offered to parents about winter safety. Prevention Taking breaks Children and adults may tire more quickly after playing or doing other outdoor activities in the winter. Take frequent breaks. Have something to drink and change wet clothing. These simple steps can prevent many problems. Clothing Layering of ...

Winter Holiday Break

PediatricEducation.org — Mon, 20 Dec 2010 00:04:37 +0100

PediatricEducation.org will be on a small holiday break for the next two weeks. New cases will start January 3, 2011. Happy Holidays to all our readers. (Source: PediatricEducation.org)

What Should be Considered for “Medically Clearing” a Patient with Psychiatric Problems?

PediatricEducation.org — Mon, 13 Dec 2010 00:09:34 +0100

Discussion Emergency room and psychiatric health care professionals may consult a pediatric health care provider to help provide initial medical evaluation and ongoing medical care to patients with primary or concurrent psychiatric problems. Sometimes, medical clearance of the patient is needed before a patient is allowed to be placed in an inpatient psychiatric facility. The medical evaluation for psychiatric illnesses depends on the presentation and underlying medical conditions. Inadvertent or intentional overdose of medication, known medication side effect or medication interactions, and drugs of abuse are common problems that present to the emergency room. A medication review including those taken by the patient and those available to the patient both legally and illegally is importa...

How Many Food Defects are Allowed?

PediatricEducation.org — Mon, 06 Dec 2010 00:43:03 +0100

Discussion During food growing, processing and preparation, appropriate steps to ensure the quality and wholesomeness of the food are important. It is not economically or humanly possible to detect and eliminate all natural or unavoidable defects in food that present no health hazards to humans. While some of these defects may cause an odious feeling such as insect parts or rodent hair, these do not pose inherent hazards to health. The Food and Drug Administration (FDA) sets standards for various foodstuffs that manufacturers must follow. The “…levels do not represent an average of the defects that occur in any of the products–the averages are actually much lower. The levels represent limits at which FDA will regard the food product “adulterated”; and subject ...

What Causes Hypocomplementemic Glomerulonephritis?

PediatricEducation.org — Mon, 29 Nov 2010 00:01:00 +0100

Discussion Post-infectious glomerulonephritis (GN) is very common and 80-90% of cases are caused by acute poststreptococcal glomerulonephritis (APSGN) which is an immune-complex mediated problem. Typically: Infection precedes the nephritis generally by a few weeks and may be difficult to identify. It can be caused by nephritogenic strains of Group A, Beta-hemolytic Streptococcus from both pharyngitis and dermatological infections, other bacteria, viruses and parasites. Interestingly, usually acute rheumatic fever and APSGN do not occur together. Abrupt onset of edema, hematuria, usually hypertension, with usually mild renal failure. Patients begin recovering usually starting within 1 week for edema and 2-3 weeks for hypertension. Urinalysis may be abnormal for several years though, especi...

What Are Causes of Diarrhea?

PediatricEducation.org — Mon, 22 Nov 2010 00:27:33 +0100

Discussion Diarrhea is increased stool volume, usually with looser consistency and increased frequency than normal. Frequency may not change however. These qualitative attributes are relative to the person’s normal bowel pattern. Acute viral gastroenteritis, one of the most common causes, usually resolves in 2-5 days. Chronic diarrhea is defined as diarrhea lasting more than 2 weeks. With chronic diarrhea there is often a cycle of infection, malabsorption and malnutrition which propagates the diarrhea. Osmotic diarrhea usually will cease once the offending agent is stopped such as juice (Toddler’s diarrhea) or dairy products (Lactose intolerance). It has a low stool electrolyte content. Weight loss and failure to thrive may be seen. Secretory diarrhea will continue even when ta...

What Are the Classification of Genetic Disorders?

PediatricEducation.org — Mon, 15 Nov 2010 00:01:21 +0100

Discussion Parry-Romberg syndrome is a rare disorder with atrophy of the soft tissues and skin of the face (usually left-sided) called hemifacial atrophy. External tissues are more affected but also eye, oral, and neck structures. Skin hypo- or hyperpigmentation and whitening of the hair and/or alopecia may occur. Trigeminal neuralgia and seizures can also be seen. Onset is usually between 5-15 years and is more common in females. The atrophy usually lasts 2-10 years and then seems to enter a stable phase. There appears to be a genetic basis for this disease but the exact mechanism is unknown. In the classification below, it would be a miscellaneous disorder. Learning Point As the tools, techniques and knowledge in the exploding field of genetics continues into the future, many of the diso...

What Are Common Toxidromes?

PediatricEducation.org — Mon, 08 Nov 2010 00:46:40 +0100

Discussion Treatment for toxicologic emergencies initially includes the traditional ABC’s of airway, breathing and circulation management. “D” includes drugs such as glucose, naloxone, thiamine, hydration and oxygen, and disability treatment (or neurological status, some say “Da Brain”) such as fluid management, hyperventilation, etc. “D” in toxicological emergencies also includes decontamination including gastric lavage, syrup of ipecac, activated charcoal, and bowel cathartics. Although antidotes do exist, there are relatively few for the plethora of potential toxic substances. Supportive treatment is a mainstay including fluid management (i.e. hydration, acidification/alkalinazation, diuresis, and dialysis), electrolyte management (i.e. glucose,...

What is the Differential Diagnosis of Back Pain?

PediatricEducation.org — Mon, 01 Nov 2010 00:01:39 +0100

Discussion Musculoskeletal complaints are common problems but back pain is less common, although probably very much underreported. Back pain is less common in younger children and then increases over time. One study of 1000 consecutive general pediatric clinic visits in patients 3-15 years, found 4 patients presenting with back pain (0.4%), this represented 6% of all patients with musculoskeletal problems. Another study of a population based cohort of children, ages 11-14 years, found a baseline one-month prevalence of 24%. After one year an additional 18.6% reported back pain. Incidence increased with age, female gender, and patients with conduct disorders or increased somatic complaints. Interestingly, backpack weight did not affect the risk of developing back pain. Females may be at inc...

How Common is Tetanus?

PediatricEducation.org — Mon, 25 Oct 2010 00:51:23 +0100

Discussion Clostridium tetani is a gram-positive bacillus that is anaerobic and spore forming. Tetanus spores are found universally worldwide in the soil and the stool of animals and people. Contamination through the skin in wounds (especially deep puncture wounds) and the umbilicus are the primary entry points. It is not unusual for the organism not to grow in cultures. The bacteria grows in dead tissues and produces a potential neurotoxin which blocks the myoneural junction. Symptoms occur gradually over 1-7 days and progress to opisthotonus. These spasms are often provoked by external stimuli. The spasms persist for about 1 week and then subside over a period of weeks in those who recover. Opisthotonus can also be caused by other diseases such as Sandifer syndrome, and phenothiazines a...

How Common is Lower Gastrointestinal Bleeding in Athletes?

PediatricEducation.org — Mon, 18 Oct 2010 00:50:27 +0100

Discussion Sports are a healthy recreational and social activity. However, various changes to the body inherent with the activity or because of increased intensity or volume of training and/or competition may cause problems for recreational and competitive athletes. Gastrointestinal (GI) symptoms occur in 30-65% of long distance runners. Upper gastrointestinal problems include nausea, emesis, gastroesohpageal reflux, and ulcers. Upper GI problems are more common in cyclists than runners though. Treatment includes avoiding eating within 3 hours of running, antacids and H2-blockers. Lower GI tract problems include cramping, increased defecation urge, increased bowel frequency and diarrhea. One well-documented serious problem is ischemic colitis. Potential causes include dehydration, decrea...

When Can A Child Stay Home Alone?

PediatricEducation.org — Mon, 11 Oct 2010 00:49:04 +0100

Discussion There is no one right answer to the difficult decision of when can a child be left home alone safely. Parents need to consider the individual child and circumstances. The majority of states also do not have legal definitions of when a child can stay home alone and it not be considered neglectful, but may have guidelines. The Child Welfare Clearinghouse from U.S. Government has a list of state agencies that can be contacted by Internet or phone for more information (see To Learn More below). Generally children around 11-13 years can be ready to stay home alone. However, children even older may not be ready if they cannot show the maturity to handle the responsibility. Learning Point Child’s General Readiness Is the child physically and mentally able to care for himself? D...

What Kind of Stretching Exercises are Recommended for Positional Plagiocephaly?

PediatricEducation.org — Mon, 04 Oct 2010 00:26:48 +0100

Discussion Positional plagiocephaly (PP) is an asymmetric head shape caused by external pressure on the occiput or other area of the head. The prevalence has increased since the 1992 recommendations began in 1992 for placing infants on their back for sleeping to decrease the risk of sudden infant death syndrome. Overall the rates vary from 0.3%-48% for infants < 1 year old. Children are at higher risk for PP at 7 weeks if they are: Male First-born birth order Having a preference for sleeping position Head placed in same end of crib Bottle feeding only Same side feeding position Low amount of time placed on abdomen (a.k.a. “tummy time”) Slow motor milestone achievement In another study, mothers of infants with positional plagiocephaly at 6 weeks thought the infants were less...

Does Silicone Gel Sheeting Work?

PediatricEducation.org — Mon, 27 Sep 2010 00:24:17 +0100

Discussion There are 3 phases of wound healing: Inflammation - the damaged vessels produce exudate to fill the wound Granulation - epithelization, re-creation of the blood vessels and reinforcing of the injured area Remodeling - fibroblast proliferation with deposition of collagen and remodeling of the area. This can last up to 2 years later. Hypertrophic scars have an increased amount of scar tissue within the original wound boundary, whereas keloids have tissue that extends beyond the borders. A recent review article graded the overall efficacy various of topical scar therapies. Silicone gel sheeting had “marked benefit” while pressure therapy (use of custom fitted pressure garments) and Imiquimod cream had “some benefit.” Polyurethane dressings and topical Vi...

“Where Do We Begin?”

PediatricEducation.org — Mon, 20 Sep 2010 00:01:22 +0100

Discussion Diagnosing and treating learning disabilities is similar to the medical process. A history of problems and concerns is taken, the differential diagnosis considered, appropriate evaluation conducted, hopefully a diagnosis made, development of an educational treatment plan, and follow-up to see how well the treatment plan is working. But like any system that provides care, the educational system has its own vocabulary, processes and rules that need to be understood and gone through. Special education is a variety of educational and other services that are designed to provide each child with an equal education. While there are many federal laws that have to be followed, each state basically oversees the school districts and other educational programs within their borders, therefor...

What Are Significant Contraindications for Breastfeeding?

PediatricEducation.org — Mon, 13 Sep 2010 00:01:36 +0100

Discussion Hepatitis B is a viral disease transmitted through blood and blood-derived fluids. It has not been noted to be transmitted by breastmilk. Chronic hepatitis B has a high prevalence rate (>8%) in all areas of Africa, Southeast Asia, much of the Middle East, parts of the Amazon River basin and the Caribbean. Chronic Hepatitis B can cause chronic liver disease, cirrhosis, and liver cancer. Incubation is about 90 days for acute infection. Only about 30-50% of patients with acute Hepatitis B infection may be clinically symptomatic. Some patients particularly those that are young ( (Source: PediatricEducation.org)

What Causes Peripheral Neuropathy?

PediatricEducation.org — Tue, 07 Sep 2010 14:08:14 +0100

Discussion Peripheral neuropathy is simply a disease of the peripheral nerves. They can be acute (30%) or chronic (about 67%). About 70% of chronic neuropathy in children is hereditary, 20% is indeterminant and 10% is acquired. Peripheral neuropathies are often present with predominantly distal involvement that is bilateral and symmetric. Sensory symptoms can include numbness, dysesthesia or ataxia. Motor symptoms often include weakness. The autonomic nervous system can also be affected with arrhythmias, hypotension, bowel or bladder problems or abnormal sweating. Learning Point The differential diagnosis of peripheral neuropathy includes: Neurologic Abetaliporteinemia Charcot-Marie Tooth Disease Chronic Inflammatory Demyelinating Polyneuropathy Dejerine-Sottas Giant Axonal Neuropathy Gu...

When Should Retinal Hemorrhages be Considered Suspicious for Non-Accidental Head Injury?

PediatricEducation.org — Mon, 30 Aug 2010 00:01:10 +0100

Discussion Shaken baby syndrome (SBS) is a form of non-accidental head injury (NAHI) that occurs when someone violently shakes a child. It may result in brain, eye and/or skeletal injury. The long-term survival is poor with cognitive/behavioral problems, cognitive impairment, cerebral palsy, and/or epilepsy as common problems. In one report 19% of the children died as a direct result of SBS and only 22% had no sequelae at discharge. SBS can be misdiagnosed particularly if it is less severe, has no external bruising (21% of cases) and no history of previous abuse (40%). SBS often occurs in infancy but can occur in children up to 8 years of age in the literature. Incomplete ophthalmological examination may under-estimate the presence and/or extent of retinal hemorrhages (RH). Complete exam...

Is This An Epidermal Cyst?

PediatricEducation.org — Mon, 23 Aug 2010 00:01:39 +0100

Discussion Epidermal cysts (sometimes called sebaceous, pilar, or epidermoid cysts) are common lesions. They often appear round, firm and are mobile, and a pore may be seen over the mass. They are closed sacs with a definite wall that are intradermal or subcutaneous in location, and occur because of epidermal cell proliferation. Spontaneous drainage of cheesy whitish material (possibly foul-smelling) from the pore may occur. Aspirates may show keratin but usually are highly cellular. They can be singular or multiple and are commonly seen on the head, neck and trunk. Breast and bone sites have also been reported. The lesions are benign and usually cause more cosmetic problems. Potentially however, a lesion’s location or size could make excision necessary for functional reasons. Ruptur...

What Criteria Could Be Used for Outpatient Treatment of Bacterial Meningitis?

PediatricEducation.org — Mon, 16 Aug 2010 00:54:55 +0100

Discussion Fortunately, vaccination against Haemophilus influenza type b, Streptococcus pneumoniae and Neisseria meningitidis has decreased the rates of bacterial meningitis but still it is an important cause of morbidity and mortality. Common pathogens by age: For neonates < 1 month of age - Streptococcus agalactiae, Escherichia coli, Klebsiella species, Listeria monocytogenes For infants and toddlers 1-23 months - Streptococcus pneumoniae, Neisseria meningitidis, Streptococcus agalactiae, Haemophilus influenzae, Escherichia coli For children > 2 years - Neisseria meningitidis, Streptococcus pneumoniae, Learning Point Criteria for considering initiating outpatient antibiotic treatment for patients with bacterial meningitis includes: Inpatient antibiotic therapy for at least 6 days No...

What Tests Are the Most Helpful As Screening Tests for Inflammatory Bowel Disease?

PediatricEducation.org — Mon, 09 Aug 2010 00:11:59 +0100

Discussion Inflammatory bowel disease (IBD) is made up of two major diseases: Crohn’s Disease (CD) and Ulcerative Colitis (UC). CD is more common than UC in children. Extraintestinal manifestations are less common in children (6%) but increase to 25% in adulthood. Children with IBD have problems with growth and often have delayed puberty. Despite the delayed puberty, many may not reach predicted adult height. Crohn’s Disease 2.1-3.7 cases per 100,000 population Gender: Males > females until puberty then about the same rate Location: Ileocolonic or colonic location predominance in children (more terminal ileum and less colonic in adults). Note bene: any area of the gastrointestinal tract can be affected from mouth to anus. Involves entire thickness of the gastrointestinal tra...

What is the Epidemiology and Genetics of the Major Phacomatoses?

PediatricEducation.org — Mon, 02 Aug 2010 00:00:16 +0100

Discussion Neurocutaneous syndromes or phacomatoses are a group of congenital or hereditary diseases that develop hamartomas of various tissues and usually additional cutaneous stigmata. Most phacomatoses have quite variable phenotypical presentations for an affected individual. Those that are listed below are common for that disease process. Learning Point Common major phacomatosis include: Sturge-Weber Syndrome Genetics: non-genetic Neurological: seizures (often contralateral to the nevus and focal), hemiparesis (again often contralateral to the nevus), mental retardation, ophthalmological problems including glaucoma Dermatological: port-wine nevus often in the trigeminal nerve’s first division, hemangiomas Other clinical features: may be associated with Klippel-Trenaunay-Weber s...

What Signs and Symptoms Are Associated with Spontaneous Bacterial Peritonitis?

PediatricEducation.org — Mon, 12 Jul 2010 00:04:35 +0100

Discussion Nephrotic syndrome is a common pediatric kidney disease affecting 16 in 100,000 children that leads to proteinuria, hypoalbuminemia, hyperlipidemia and edema. The cause is usually minimal change nephrotic syndrome (77%), focal segmental glomerulosclerosis (8%), membranoproliferative glomerulonephritis (6%) and other causes (9%). Response to steroid therapy with normalization of urine protein levels by 8 weeks of treatment has good sensitivity and specificity of predicting minimal change nephrotic syndrome. The nephrotic syndrome initial evaluation is recommended to include: All patients Urine - urinalysis, urine protein/creatinine ratio (first morning) Serum - electrolytes, blood urea nitrogen, creatinine, glucose, albumin, cholesterol level, complement 3 level, purified p...

What’s the Difference Between A Stye, Hordeolum and Chalazion?

PediatricEducation.org — Mon, 05 Jul 2010 00:09:21 +0100

Discussion There is confusion with the terms stye, hordeolum and chalazion because of the general public usage and the most precise medical usage. Even in the more precise usage, there is difficulty because of the overlap in the anatomy. Hordeola and chalazia can be caused by blepharitis or generalized eyelid inflammation. A differential diagnosis of blepharitis can be found here. Learning Point Stye is a term used often by the general public to denote a small localized swelling/inflammation of the eyelid. A hordeolum (or a stye) is term used by the medical profession to denote a localized inflammation and/or infection of the hair follicles of the eyelid or the meibomian glands. It is usually an acute problem but can be recurrent. These are usually somewhat painful with erythema and the...

How Many Shunt Malfunctions Do Children with Venticuloperitoneal Shunts Have?

PediatricEducation.org — Mon, 28 Jun 2010 00:04:11 +0100

Discussion Hydrocephalus can occur for many reasons including congenital anomalies (e.g. spina bifida, aqueductal stenosis, Arnold-Chiari or Dandy-Walker malformations), trauma, intraventricular hemorrhage and meningitis. The common pathway is cerebrospinal fluid accumulation causing pressure effects on the central nervous system. While not perfect, ventriculoperitoneal shunts allow many children with hydrocephalus to live symptom free lives and many others to have much improved quality of life. In the pre-shunt era, only 20% of children survived to adulthood and 50% had brain damage. One major improvement was the development of the DWT pressure valve by Roald Dahl (the famous author), Stanley Wade (engineer particularly of hydraulic pumps) and Kenneth Till (first full-time pediatric neuro...

Is This Precocious Puberty?

PediatricEducation.org — Mon, 21 Jun 2010 00:02:52 +0100

Discussion During normal pubertal development “[h]igh-amplitude pulses of [gonadotropin releasing hormone] cause pulsatile increases in the pituitary gonadotropin-luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Increased LH levels stimulate production of sex steroids by testicular Leydig cells or ovarian granulosa cells. Pubertal levels of androgens or estrogens cause the physical changes of puberty….” These include growth spurt, breast budding, public and axillary hair, and penile and testicular enlargement. Production of ovarian follicular maturation and spermatogenesis also occurs. Normal female puberty (mean age in years) Thelarche (breast budding caused by estrogens) is age 9 years Adrenarche (pubic hair caused by androgens) is age 10 years for Cau...

What Are Fine Motor Problems that I Should Refer To an Occupational Therapist?

PediatricEducation.org — Mon, 14 Jun 2010 00:01:12 +0100

Discussion Fine motor movements affect almost everything we do on a daily basis such as moving and manipulating tools and objects, preparing and eating meals, personal hygiene, communicating through writing and typing, counting change, opening doors, etc. Occupational therapists (OTs) are highly skilled professionals who assist children and families in some of the most important activities of life. OTs may work in hospitals, clinics, schools, rehabilitations centers and other locations, and a master’s degree is needed for an entry level position. Pediatric occupational therapists consider the wide range of developmental attainment for children. Depending on the problem, they may also need to consider rehabilitation needs if skills are lost through disease or accident in a child. OTs ...

How Do You Evaluate and Treat a Thyroid Nodule?

PediatricEducation.org — Mon, 07 Jun 2010 00:36:39 +0100

Discussion Endemic goiter is not a common problem in the U.S. with the addition of iodine to food particularly salt. Thyroid nodules are relatively unusual for children (solitary nodules 0.22-1.35%) compared with adults (4%). Malignancy unfortunately is more common in children than adults; for solitary nodules 15-25% compared to 4% in adults. During adolescence the rate of malignancy decreases to adult levels in late adolescence/early adulthood. Learning Point Most single and multiple thyroid nodules are benign but not all and this makes treatment decisions more difficult. Nodules which have obvious malignant changes require surgical treatment and medical followup. It is the nodules which show indeterminant pathology that can be associated with increased malignancy risk which are particula...

What Are the Complications of Pneumonia?

PediatricEducation.org — Mon, 31 May 2010 00:27:40 +0100

Discussion Pneumonia is an inflammation of the lung parynchema with consolidation of the tissue and filling of the alveolar air space with exudate, fibrin and inflammatory cells. It is the most common cause of pediatric death in the world and is described as the “forgotten killer of children” by UNICEF and the WHO. This is particularly true in developing countries. But while the United States and other developed countries see fewer deaths and morbidity related to pneumonia, complications of pneumonia still occur. The most common organisms causing outpatient pneumonias in the U.S. are: Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Streptococcus pneumoniae, and a variety of respiratory viruses. Vaccines to combat pneumonia are available and include: Haemoph...

What is a Norwood Procedure?

PediatricEducation.org — Mon, 24 May 2010 00:06:31 +0100

Discussion Some main surgical procedures for congenital heart disease include: Atrial Septostomy Used to increase mixing of blood at the atrial level such as transposition of the great arteries, tricuspid atresia and mitral atresia Shunt: Balloon-tipped catheter creates a larger hole in the atria Blalock-Taussig Shunt Used for low pulmonary flow states such as Tetrology of Fallot, HLHS, tricuspid atresia Uses systemic arterial flow to increase pulmonary flow Regular Shunt: Subclavian artery to pulmonary artery by direct anastomosis or by graft Glenn Shunt Used often as intermediate step to a Fontan procedure, especially in infancy and toddlerhood Uses some systemic venous return to increase pulmonary flow Shunt: Superior vena cava to right pulmonary artery by graft Fontan Shunt Use...

What is the Differential Diagnosis of Hyperphosphatasemia?

PediatricEducation.org — Mon, 17 May 2010 00:05:20 +0100

Discussion Alkaline Phosphatase (AlkPhos) is found mainly in the bone and liver but also in the intestine, kidney, placenta, lung, neutrophils, lymphocytes, and endothelium. The levels are significantly increased over normal adult levels during childhood and adolescence. They increase during puberty, during pregnancy and increase again slightly in older people. They can also be increased after liver and biliary surgeries. There are some differences between boys and girls with boys having a slightly higher AlkPhos than girls. Benign hyperphosphastemia of infancy and childhood is a benign disease with an unknown etiology. It is often found incidentally during routine blood analysis. It is most common in children but has been reported in adults. Diagnostic criteria include: < 5 years of age ...

We’re Moving. How Can I Help My Child?

PediatricEducation.org — Mon, 10 May 2010 00:02:48 +0100

Discussion Even normal life changing events can be stressful for individuals and families. Boyce categorizes transitions in this way: Normative or non-normative transition Normative transitions are events that occur to most children and families under usual circumstances, and may be planned or unplanned Entering kindergarten Moving to a new location (i.e. planned moved because of new job or unplanned move because of job loss) Beginning a new activity (e.g. sport, instrument) Beginning a new job Death of pet Non-normative transitions are unanticipated events that do not occur at the normal expected time Parental death Divorce Biological and psychosocial transitions Biological and psychosocial transitions often go hand-in-hand such as puberty Puberty Rites of passage (e.g. bar/bat mi...

What Causes Gastrointestinal Bleeding?

PediatricEducation.org — Mon, 03 May 2010 00:01:46 +0100

Discussion Blood mixed in the stool is usually from higher in gastrointestinal tract, while blood coating the stool is usually from the anal canal or rectum. Brisk hemorrhage (i.e. hematochezia) with fresh blood and clots is distal to the Ligament of Trietz. Fresh blood is often from the left colon or maroon-colored if from the right colon. Melena is passage of dark, tarry stools. Melana is usually from the esophagus, stomach or duodenum but all areas of the small bowel may be affected. Tarry stools can also be caused by bismuth, iron or licorice ingestion. There is an artificial dividing line between upper and lower disease processes, because rapid transit of blood from the upper GI tract can produce hematochezia and slow transit of blood in the lower tract can cause melena. Neonates and...

What Causes Splenomegaly?

PediatricEducation.org — Mon, 26 Apr 2010 00:01:24 +0100

Discussion Second opinions can often be tricky as there are numerous reasons for the consultation. Often a healthcare provider will send a patient to confirm, deny or interpret a finding, e.g. a possible abnormal growth pattern in an infant. There may be a chronic problem that isn’t responding to the 2nd, 3rd or 4th line treatment, e.g. constipation. Maybe it is an ill-defined problem that despite appropriate evaluation, treatment and time, is not improving, e.g. fatigue. Communication issues often complicate the matter. Perhaps the healthcare provider may not adequately explain the problem to the family, or the family is not adequately listening or understanding the provider. There is always someone - patient, family member or health care provider - who truly has a question that the...

I Need to Review the Periodic Fevers

PediatricEducation.org — Mon, 19 Apr 2010 00:58:47 +0100

Discussion Fevers that are perceived by patients, families and health care providers as not following a “normal” pattern bother everyone. Patients and families may have different expectations than healthcare providers about the actual temperature measurement, duration of the fever, and other assorted factors such as where the temperature was taken, the instrument used and whether antipyretic medication had been used. Luckily for most patients, fever, even true recurrent fevers, are often self-limited and have good prognoses. Fever patterns include: Recurrent fever Multiple episodes that occur at inconsistent intervals involving multiple organ systems, fever is one component Multiple episodes that occur at inconsistent intervals involving a single organ system Single episode ...

How Do You Treat Urticaria Pigmentosa?

PediatricEducation.org — Mon, 12 Apr 2010 00:01:39 +0100

Discussion Urticaria pigmentosa (UP) is one of the cutaneous forms of mastocytosis. Patients can present at birth and 80% of pediatric patients present by age 1, with both genders equally affected. Classical UP lesions in children are more hyperpigmented but may be erythematous, are 5 mm mean diameter and well demarcated. The distribution includes the trunk especially but face, scalp and other areas can be affected. Lesions may be flat or papular and may blister. The blisters resolve without scarring and these episodes usually remit by age 3. Darier’s sign (stroking of a lesion creating a wheal and flare response) is usually positive in patients not taking antihistamines. Dermatographism is usually not seen. Other forms of UP include plaque-like lesions, and nodular lesions, while ot...

What Are the Long Term Neurological Outcomes of Premature Infants with IVH?

PediatricEducation.org — Mon, 05 Apr 2010 00:01:55 +0100

Discussion With the advent of multiple new technologies and the birth and maturation of neonatology as a pediatric specialty has come dramatically improved outcomes for premature and full term neonates. Mortality has decreased and more children that previously would have died, now live. Decreasing birth weight and decreasing gestational age are predictors of potential chronic neurodevelopmental problems. Other problems that premature infants face include retinopathy of prematurity, anemia, sepsis, necrotizing enterocolitis, pulmonary hypertension, and therapies such as oxygen and ototoxic drugs that are necessary for survival but that put the infant at increased risk for chronic morbidities. The infant central nervous system is particularly vulnerable and premature infants are at risk for ...

What is POTS Again?

PediatricEducation.org — Mon, 29 Mar 2010 00:05:29 +0100

Discussion Orthostatic intolerance are problems experienced when moving from a supine to upright position that are relieved when moving back to a supine position. Orthostatic intolerance can be due to autonomic or other compensatory dysfunction. Acute orthostatic intolerance includes syncope, simple faints and initial orthostatic hypotension. Syncope is a transient loss of consciousness and postural tone. It is caused by reduced cerebral blood flow with rapid recovery. Syncope may be caused by orthostasis or other causes such as cardiac arrhythmias, coronary artery disease or muscle diseases. Simple faint is also referred to as vasovagal syncope or reflex syncope. It is a common problem and patients are well before and after the occurrence. Precipitators include standing for prolonged per...

Why Do You Check the pH of the Eye after Chemical Exposure?

PediatricEducation.org — Mon, 22 Mar 2010 00:36:08 +0100

Discussion About 30% of chemical eye injuries occur at home with 60% occurring in the workplace. Splashing is the most common cause and fortunately only about 20% of injuries have significant disability. About 35% of the eye injuries are in pediatric patients. In one study of hospitalized patients for eye injuries the most common problem was an open wound of ocular adnexa (26%), followed by an orbital floor fracture (25%). Chemical eye injuries accounted for only 1.5%. Patients with chemical eye injuries present with pain and foreign body sensation often, but they may also complain of increased tearing, photophobia and reddened eye. Injuries appear different if the chemical is acid or alkali. Acids break apart into hydrogen ions and anions. The hydrogen alters the pH and the anion cau...

What Causes Pharyngitis?

PediatricEducation.org — Mon, 08 Mar 2010 00:10:32 +0100

Discussion Sore throat caused by group A, beta-hemolytic streptococcus (GAS) is classically characterized as a patient with a constellation of various symptoms including fever, headache, emesis, sore throat, palatal petechiae, abdominal pain, sand-papery skin rash and often with a history of close contact. The rapidity of onset is relatively short but generally not characterized as rapid. Patients with upper respiratory tract symptoms or allergic symptoms including rhinitis, conjunctivitis, voice changes (e.g. raspy, croupy, laryngitic) tend to have viral etiologies for their sore throat. Differentiating between viral pharyngitis and GAS is a common conundrum. Rapid antigen testing and throat cultures assist in making the proper diagnosis, so that nonsupprative complications such as acute ...

Learning From the Past. What is Chlorosis?

PediatricEducation.org — Mon, 01 Mar 2010 00:01:20 +0100

Discussion In practicing medicine, clinicians try to provide the best care for the patients and families they serve. They usually try to use the most current information available and apply it to the specific patient situation, yet medicine is an ever-changing science and art. Disease theories change. For example, mental illness was once thought to be caused by the lunar cycles thus the name “lunacy” or “lunatic.” Overtime it became known that neurochemical and genetic factors play a role. Scientific information is re-analyzed or classified. For example, the organism that causes cat-scratch disease has had 3 names since 1991 - Afipis felis, Rochlimacae henselae, and currently Bartonella henselae. Disease treatments are often changing as new information becomes avail...

What Causes Diurnal Enuresis?

PediatricEducation.org — Mon, 22 Feb 2010 00:34:14 +0100

Discussion Type 1 diabetes mellitus or insulin-dependent diabetes mellitus (DM) is a chronic metabolic disorder caused by the lack of insulin. Langerhans cells in the pancreas make insulin and congenital absence or destruction of the cells produces DM where patients are dependent on exogenous insulin. An estimated 3/1000 children develop DM by age 20. Overall there is an incidence of 15/100,000 annually for DM. Insulin and diet treatment is necessary but needs to be tailored to the individual. Intercurrent illnesses also require special treatment so patients do not progress to ketoacidosis. To read more about intercurrent illness treatment click here. Patients can also have long-term side effects of their diabetes including other endocrinopathies/autoimmune diseases, growth problems and r...

What is the Seroconversion Rate of Mumps Vaccine?

PediatricEducation.org — Mon, 15 Feb 2010 00:13:37 +0100

Discussion Mumps is caused by a paramyxoviridae family virus and humans are the only known host. The spread is from infected respiratory tract secretions. Mumps causes swelling of one or more salivary glands, in particular the parotid glands. Up to 1/3 of patients do not have salivary swelling that is apparent. Parotitis in children is usually not due to mumps and can be caused by several other viruses including coxsackieviruses, cytomegalovirus, enteroviruruses, human immunodeficiency virus, and parainfluenza virus. It can also be causes by Staphlococcus aureus, mycobacterium (nontuberculous), cirrhosis, diabetes, drug reactions and malnutrition. Mumps complications include central nervous system problems (including hearing problems, cerebellar ataxia, radiculitis), arthritis, myocarditi...

What is the Differential Diagnosis of Failure to Thrive?

PediatricEducation.org — Mon, 08 Feb 2010 00:24:36 +0100

Discussion Failure to Thrive (FTT) is defined as persistent weight below the 3rd percentile for age in infants and young children. The associated terms “Failure to gain weight” (FGW) or “Lack of Normal Physiologic Growth and Development” are more precise, especially for children who are not below the 3rd percentile but are losing weight over time and/or crossing percentile lines on their growth curve. For general growth parameters see How Do I Calculate Mid-Parental Height and Other Growth Parameters? About 70-80% of FTT cases have psychosocial problems that are associated with the FTT or the primary cause of the FTT. Children of older ages may also have FTT such as those with psychosocial dwarfism or eating disorders. Children with FTT have a wide range of appearan...

What Is the Differential Diagnosis of Attentional Problems?

PediatricEducation.org — Mon, 01 Feb 2010 00:23:56 +0100

Discussion Attentional problems are a clinical diagnosis. Some people use a functional definition of attentional difficulties that disrupt the normal activities of the patient and/or family. Attention Deficit Disorder (with or without hyperactivity, i.e. ADD, ADHD) has specific criteria for its diagnosis using the Diagnostic and Statistical Manual (version IV). Children with attentional problems present in a wide variety of ways, including poor school performance, behavioral problems, personality changes, and inappropriate or antisocial behavior. History is very important and should include school history with results of other evaluations, typical day activities and behaviors, birth history (including possible teratogens and substance abuse), developmental history (including possible los...

What Causes Respiratory Distress?

PediatricEducation.org — Mon, 25 Jan 2010 00:01:37 +0100

Discussion Pectus excavatum is a deformation of the chest wall where the sternum and ribs grow abnormally to form a concavity relative to normal positioning. Pectus carnitum is similar but forms a convexity. Pectus excavatum is much more common (90%) than pectus carnitum (7-8%) or other congenital chest wall deformities (2-3%). Pectus excavatum is usually noted at birth or in the first year of life. It may be relatively minor (the most common) or quite severe (rarer) with the concavity displacing internal organs and possibly causing pulmonary and/or cardiac abnormalities. Usually it is relatively stable, but may progress especially during times of rapid growth such as puberty. Thankfully most patients do not need treatment but severe pectus excavatum may cause psychological distress becaus...

What are the Risks of Infertility after Pelvic Inflammatory Disease?

PediatricEducation.org — Mon, 18 Jan 2010 00:22:45 +0100

This study included patients 14-37 years but without subgroup analysis of adolescents. In another study, these researchers found that barrier methods (especially male condoms) significantly helped to prevent chronic pelvic pain, recurrent PID, and infertility. Questions for Further Discussion 1. What are the recommended treatment options for PID? 2. What are the recommendations for treating partners of patients with known PID and how are the partners contacted locally? 3. What are the legal requirements for treating minors with sexually transmitted infections? Related Cases Disease: Pelvic Inflammatory Disease | Chlamydia Infections Symptom/Presentation: Abdominal Pain | Pelvic Pain | Vaginal Discharge Specialty: Adolescent Medicine | Emergency Medicine | Infectious Diseases | Obstetrics...

When Can an Infant See Color?

PediatricEducation.org — Mon, 11 Jan 2010 00:21:33 +0100

Discussion Infants are hyperopic (farsighted) at birth because of the relatively short axial length of the globe and ocular optics. Astigmatism occurs in 15-30%. These refractive errors are gone for most infants by 9-12 months. Newborns can fixate at birth but accurate visual fixation occurs by 6-9 weeks. Accommodation (fixating on near objects) is also evident at birth but is not accurate until about 2-3 months. Visual acuity (defining fine details) is normal by 6-8 months. Stereopsis (3-D vision) has a rapid onset at 3 months and is normal around 6 months. Learning Point Contrast sensitivity (the ability to detect brightness differences or shades of grey) occurs by 10 weeks. Color vision begins as early as 2 weeks (red) and by 3 months is normal. Questions for Further Discussion 1. List ...

What Causes Different Types of Cries?

PediatricEducation.org — Mon, 04 Jan 2010 00:03:53 +0100

Discussion Crying is a primary vocalization for infants and small children, and remains a part of the vocalization repertoire over a person’s lifetime. Infant crying leads to feeding and nutrition for the child, protection (skin irritation from diaper contents, pain), and increased social interaction (through attempts to calm). Crying is described in terms of quantity and quality, with much written about the quantity of crying, as in the “colicky” infant. For more information about colic see What Should I Do? I Just Can’t Get Him to Stop Crying? Less is written about the qualitative features of crying, but many parents are able to pick their own child’s cry out of many children who are crying. Seasoned clinicians are able to walk down a hallway and point out ...

What Causes Red Eyes?

PediatricEducation.org — Mon, 28 Dec 2009 00:01:39 +0100

Discussion Epidemic keratoconjunctivitis is an acute viral disease usually caused by adenovirus types 8, 19, and 37, but also other viruses such as echoviruses. The virus is spread by contaminated secretions directly or indirectly between humans with an incubation period of 4-10 days. It can be transmitted from symptom onset to 12 days later. It is usually associated with decreased visual acuity, watery discharge, pain, photophobia and erythema of the conjunctiva. It can occur unilaterally or bilaterally. Systemic complaints can also occur such as low grade fever, headache, lymphadenopathy and fatigue. Subcorneal infiltrates develop and may persist for up to 2 years and can cause permanent scarring. Learning Point Usually the common causes of red eyes can be managed by a primary care physi...

What Causes Peeling Fingers and Toes?

PediatricEducation.org — Mon, 14 Dec 2009 00:32:42 +0100

Discussion Palmar and plantar hyperkeratosis is localized or diffuse thickening of the palmar and solar stratum corneum. It can occur in isolation or as part of a generalized disorder such as Sjögren-Larsson syndrome, Conradi’s syndrome, psoriasis, and hypohidrotic ectodermal dysplasia. Treatment includes agents to increase exfoliation such as lactic acid, salicylic acid or urea and soaking and mechanical exfoliation with a pumice stone or scalpel. These are used so tissue build up is decreased. Emollients need to be applied to help prevent fissuring from mechanical stress. Other possible treatments include topical psoralens with ultraviolet A light, topical retinoids or corticosteroids. Learning Point The differential diagnosis of desquamating digits includes: Localized or sem...

Hello world!

PediatricEducation.org — Sun, 13 Dec 2009 02:13:13 +0100

Welcome to WordPress. This is your first post. Edit or delete it, then start blogging! (Source: PediatricEducation.org)

How Can I Test for Nickel?

PediatricEducation.org — Mon, 07 Dec 2009 00:36:26 +0100

Discussion Allergic contact dermatitis (ACD) is often under-recognized but a frequent problem. Atopic dermatitis and irritant skin reactions are often difficult to distinguish from ACD. There are about 100 common sensitizers that cause ACD including nickel and poison ivy. Most are small molecules that can easily penetrate the skin and cause a delayed T-cell hypersensitivity reaction (Type IV). ACD reactions usually are linear or geometric lesions that are well demarcated and persistent. Nickel is found in many household and wardrobe items including dental braces, jewelry, clothing fasteners such as clasps, snaps, buckles and zippers, coins, and tools (including cellphones, eating utensils, etc.). Most people require prolonged and intimate contact with items before having ACD; general cont...

I Need A Refresher about Straddle Injuries

PediatricEducation.org — Mon, 30 Nov 2009 00:27:20 +0100

Discussion Presurgical evaluations are very important for any patient particularly if a patient does not have a medical home or consistent health care providers. They also are particularly important for patients with chronic or complicated medical conditions and therefore pediatric health care providers are often asked to assist their dental and surgical colleagues in pre-operative evaluations. An overview of the elements of a preanesthesia evaluation can be found here, including the American Society of Anesthesiologists (ASA) airway classification. A careful history for any problems with anesthesia should always be asked and documented, especially for any difficulties with waking up from anesthesia, fever or muscle problems. These could indicate possible malignant hyperthermia and an ove...

Is This Really Weed?

PediatricEducation.org — Mon, 23 Nov 2009 00:01:36 +0100

Discussion Marijuana (Cannibis sativa) is the most common illicit drug abused in the United States, but is also used in certain circumstances for pain and anxiety control in patients with chronic disease. It is estimated that 102 million Americans (~40%) have used marijuana at some time in their lifetime. Children who use marijuana, especially at a younger age, are more likely to abuse other substances such as cocaine or heroine. Therefore patients using any illicit substance should be evaluated for additional substance abuse. Acute problems caused by marijuana include tachycardia, impaired coordination, increased respiratory illnesses, and problems with learning, memory and social behavior. Chronic abuse has been associated with anxiety, depression, schizophrenia and suicidal ideation. Ma...

What Types of Community Services Are Available?

PediatricEducation.org — Mon, 16 Nov 2009 00:01:16 +0100

Discussion Health care providers often view the patient through the medical lens and may not see the full view of all aspects of patients and families lives. Even many who work in community centered locations may not be aware of the breadth of services wanted and needed by families. Medical and community services are diverse in every location and often change as funding becomes available or dries up. One of the most difficult tasks for a health care provider (and patients and families) is to move to a new location and need to locate and access various services. Health care providers who take care of patients and families from a wide geographical area are at an additional disadvantage as the practitioner often is not aware of the availability or non-availability of local community services...

How Do You Define Professionalism?

PediatricEducation.org — Mon, 09 Nov 2009 00:15:25 +0100

Discussion The American Academy of Pediatrics states “[p]rofessionalism has been a central and defining feature in medicine….Pediatricians have a special status in society as priviledged and trusted advocates for the well-being of children. Pediatricians have a responsibility to use their knowledge, skills, and influence to advocate for children and their interests in all domains of society, not just in health care.” The American Board of Pediatrics has endorsed eight components of professionalism for teaching and evaluation of resident physicians. These are: honesty and integrity, reliability and responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication and collaboration, and altruism and advocacy. Learnin...

What Evaluation is Appropriate for Complex Febrile Seizures?

PediatricEducation.org — Mon, 02 Nov 2009 00:23:48 +0100

Discussion Febrile seizures are the most common type of seizures in children. They affect about 2-5% of all children. Febrile seizures are characterized into two groups: simple febrile seizures and complex febrile seizures. Basically, if the child does not meet the criteria for a simple febrile seizure it is called a complex febrile seizure. The main characteristics are outlined below: Simple Febrile Seizure Complex Febrile Seizure Age 6-60 months < 6 months or > 60 months Duration < 15 minutes > 15 minutes Type Generalized Focal seizures tonic-clonic Tonic and/or clonic Partial seizure with/without generalization Head or eye deviation to one side Unilateral transient paralysis after seizure Loss of musc...

What Problems Do I Need to Screen This New International Adoptee or Domestic Foster Care Child For?

PediatricEducation.org — Mon, 26 Oct 2009 00:22:20 +0100

Discussion There is much overlap between immigrant children and children in foster care - particularly around adoption. Immigrant children are defined as those who are legal and undocumented immigrants, refugees and international adoptees. Children in domestic foster care if not reunified with their parents may be adopted by relatives (kinship permanency) or with non-relatives (national adoptees). Additionally, international adoptees and children initially or recently placed into foster care need similar medical evaluations. Children that are adopted, including those who had been in foster care, have higher rates of asthma, moderate or severe health problems, developmental delays, psychosocial problems (problems with emotion, concentration, behavior, getting along with others, etc. ), lea...

What Are Those Blood Group Antigens and Isn’t There Some Treatment I Can Give?

PediatricEducation.org — Mon, 19 Oct 2009 00:40:33 +0100

Discussion Hemolytic disease of the newborn is usually considered if there is a severe or rapidly developing hyperbilirubinemia, a maternal positive antenatal antibody screening or severely anemic or hydropic fetus, a positive direct Coombs test, hemolysis seen on blood smear, or prolonged hyperbilirubinemia. A differential diagnosis of the multiple causes of unconjungated hyperbilirubemia can be found in a previous case, and a review of the epidemiology of Rh negative HDN can also be found in another previous case. Learning Point Causes of severe unconjungated hyperbilirubinemia due to red blood cells causes includes: Major Blood Group Antigen ABO incompatibility Rhesus group incompatibility (Anti-D, Anti-C and Anti-E) Minor Red Blood Cell Antigens Anti-Duffy Anti-Kell Anti-Kidd Anti-...

Is There Arsenic in My Environment?

PediatricEducation.org — Mon, 12 Oct 2009 00:37:59 +0100

Discussion Arsenic (As) is a semimetal found in Group 15 of the Periodic Table of Elements which is shared by Nitrogen, Phosphorus, Antimony and Bismuth. It is not considered by chemists as a heavy metal, but is often lumped in with Mercury and Lead because all have similar toxic affects. Elemental arsenic is not toxic itself, but inorganic and organic compounds are toxic. Trivalent inorganic compounds are particularly toxic because they are highly lipid soluble. Arsenic is bound by plasma proteins, hemoglobin and leukocytes and then is concentrated in the gastrointestinal tract, liver, kidneys, spleen, and lungs. Acute toxicity can cause an acute paralytic syndrome with cardiovascular collapse, central nervous depression and death within hours. It can also cause an acute gastrointestinal ...

What is the Appropriate Treatment for a Pedal Puncture Wound?

PediatricEducation.org — Mon, 05 Oct 2009 19:19:02 +0100

Discussion Ciprofloxacin and other fluoroquinolones have demonstrated cartilage and joint toxicity when administered to immature laboratory animals. Therefore health care providers have been reluctant to use fluoroquinolones in young children and voluntarily have avoided them. However in 2002, more than 182,000 courses of fluoroquinolones were administered to children. Research data is limited but the pediatric safety profile appears to be similar to the adult safety profile. Current indications for fluoroquinolones include complicated urinary tract infections, treatment of opportunistic infections in immunocompromised patients such as patients with cancer, patients with cystic fibrosis and certain Shigella and Salmonella infections, and for inhalational anthrax. Fluoroquinolones are often...

When Does the Rash of Roseola Occur?

PediatricEducation.org — Mon, 28 Sep 2009 00:01:38 +0100

Discussion Rashes, particularly ones caused by viruses, are common presenting problems. In his first edition of Pediatrics, Dr. Rotch spent 72 pages describing infectious exanthemata. The cause of the exanthemata was unknown at the time, and thankfully many of those that he wrote of have been eradicated (smallpox), have effective vaccines to prevent (measles, rubella, varicella) or effective antibiotics for treatment (streptococcus). Dr. Rotch ends his extensive treatise with a table describing “the chief points of differential diagnosis in the exanthemata.” This is what was state-of-the-art in 1896 with his spellings: Variola (Smallpox) Incubation: 12 days Prodromata: 3 days Efflorescence: macules, papules, vesicles, pustules Desquamation: large crusts Complication and seque...

What Are the Pros and Cons to Different Wound Closure Devices?

PediatricEducation.org — Mon, 21 Sep 2009 00:01:35 +0100

Discussion About 7 million traumatic wound lacerations are repaired each year in emergency departments. Many more are repaired in practitioner’s offices. The ideal wound closure device and technique would be easy to perform consistently, quick to perform, be able to be performed in all clinical circumstances, painless, without the need to remove the device, have excellent cosmetic results and be cost effective. All of the current options for wound closure (i.e. sutures, staples, surgical tapes and tissue adhesives) do not meet all these criteria and therefore choosing among the options is necessary. Sutures have been available for millennia. Staples and surgical tapes have been around for less time. The Federal Drug Administration has only sanctioned general use of tissue adhesives i...

What Are Some Common Presentations for Inborn Errors of Metabolism?

PediatricEducation.org — Mon, 14 Sep 2009 00:01:10 +0100

Discussion Each inborn errors of metabolism (IEM) by itself is often rare but taken as a whole, IEM are common. IEM often present in the newborn or infancy periods but can present at any time including adulthood. The genetic defect often causes a problem in the catabolism or synthesis of carbohydrates, fats, or proteins. The defect causes a blockage in the metabolic pathway with intermediate molecules accumulating (often toxic accumulations) before the blockage and metabolites after the blockage being scarce (inadequate energy production/utilization). Diet and stresses including surgery, trauma, and illness often can trigger intermittent decompensation. Common IEM include: Carbohydrate metabolism - carbohydrate intolerance, geoneogenic and glycogenolytic disorders, glycogenic storage def...

What Are The Options for Treating Excessive Salivation?

PediatricEducation.org — Mon, 07 Sep 2009 00:01:02 +0100

Discussion Drooling, excessive salivation, hypersalivation, or sialorrhea can be a big problem for children. It can cause wet clothing necessitating bibs or multiple changes of clothing. It can cause dermatitis of the face, neck and chest, with possible skin breakdown and/or possible secondary infection. Sialorrhea can also potentiate the spread of common infections to others though direct or indirect contact with the saliva. It can also cause impaired social interaction as noted above. Therefore it is a problem that should be taken seriously and treated as necessary. Sialorrhea is generally considered abnormal if it occurs during the day after the age of 3-4 years. Most people affected have some other neurological problem including cerebral palsy or in adult populations, patients with Pa...

How Do I Calculate Mid-Parental Height and Other Growth Parameters?

PediatricEducation.org — Mon, 31 Aug 2009 00:02:18 +0100

Discussion Parents and pediatric healthcare providers are very concerned with children’s growth as it is such an important marker of their health status. Healthcare providers know, but parents often need to be educated, that it is not the exact measurements but the change in height, weight or head circumference that is the most important determinant. Therefore knowing some basic growth parameters and their changes over time are extremely important for analyzing children’s growth patterns. Children that appear to not be following these general patterns may do so for many reasons such as prematurity, chronic illness, or genetic constitution. But children who are not following these general patterns need to be at a minimum monitored closely and an appropriate evaluation begun if t...

If I Had To, How Would I Use Anti-Venom?

PediatricEducation.org — Mon, 24 Aug 2009 00:01:50 +0100

Discussion In the United States there were 3264 snake bites reported to the American Association of Poison Control Centers in 2007. Bites and envenomations were the 13th most common substances involved in human exposures as reported by the same group. There are basically two types of venomous snakes in the U.S.: Family - Crotalidae Pit Vipers - copperheads, rattlesnake, cottonmouth, sidewinder About 98-99% of all envenomations Occur more in warmer months but can occur at any time Bite reactions: Extensive local reaction with severe pain and extensive regional swelling that can occur in as little as 10-30 minutes. Coagulation disorders may follow such as epistaxis, purpura, hemolysis or disseminated intravascular coagulation occurring in 30 minutes-48 hours. Shock can also be seen at th...

What Are the Complications of Cardiothoracic Surgery?

PediatricEducation.org — Mon, 17 Aug 2009 00:01:25 +0100

Discussion Congenital diaphragmatic hernia (CDH) occurs in 1 / 2000-3000 live births. Its overall mortality has been hard to determine as many infants die in-utero or just after birth before transfer for surgical care. One study found that ~61% of fetuses with CDH are live born. Many of these fetuses had other congenital anomalies. Mortality after live birth is ~ 40-62%. There are 3 major types of CDH: Bochdalek hernia which occurs posterolaterally Morgagni hernia which occurs anteriorly Hiatus hernia Left sided Bochdalek hernias are the most common (85%). Treatment currently includes fetal surgical repair, post-natal surgical repair and critical care. Learning Point Cardiothoracic surgical repairs are critical for treatment of CDH and other congenital heart disease or congenital malf...

What Forms of Vitamin K Exist?

PediatricEducation.org — Mon, 10 Aug 2009 12:15:00 +0100

Discussion Vitamin K is critical for prevention of Vitamin K Deficiency Bleeding (VKDB) formerly known as hemorrhagic disease of the newborn. Dr. Charles Townsend first described this entity in 1894. Vitamin K is necessary for the synthesis of prothrombin and Factors VII, IX and X. Vitamin K stores are low at birth and also are low in breast milk. VKDB has 3 presentation variants: Early Bleeding occurs in first 24 hours. Bleeding sites - intraabdominal, intracranial, intrathoracic, skin and subperiosteal Generally occurs with mothers who are taking anticonvulsants, warfarin or anti-tuberculosis medications Classical Bleeding occurs usually between day of life 1-7 days (especially at 2-5 days) Bleeding sites - circumcision, gastrointestinal, intraabdominal, intracranial, intrathoraci...

What Causes Macroglossia?

PediatricEducation.org — Mon, 27 Jul 2009 00:01:20 +0100

Discussion Children with Down syndrome have a number of potential medical problems that need to be screened for and current recommendations can be found from the American Academy of Pediatrics (see To Learn More below). These include congenital cardiac anomalies, atlanto-axial instability, hypothyroidism, and leukemia and its variants. Additionally, children with Down syndrome often have chronic otitis media and airway abnormalities because of smaller airways and hypotonia. Dental abnormalities are also common. Learning Point Macroglossia is not a common problem but the differential diagnosis is broad. Often macroglossia is due to a genetic abnormality or relative enlargement due to adjacent structure size or impingment upon the tongue. The differential diagnosis of macroglossia includes: ...

Does This Sacral Dimple Need to be Evaluated?

PediatricEducation.org — Mon, 20 Jul 2009 00:01:53 +0100

Discussion Skin dimples over the spine commonly referred to as sacral dimples are common minor congenital anomalies, estimated to occur in 3-8% of children. When a clinician sees a skin dimple, the possibility of occult spinal dysraphism (OSD) usually crosses the mind. OSD is a wide-range of skin-colored spinal column and neuraxis abnormalities that are caused by abnormal neurulation. OSD lesions include dermal sinuses, tethered cord, lipomyelomeningocoele, and diastematomyelia. OSD can present with a variety of abnormalities, but is also frequently asymptomatic and can present at any age. Skin abnormalities accompany 50-80% of OSD. Other presentations of OSD include: Skin Dimples/pits Dermal sinuses Hypertrichosis Lipoma or other mass Pigmented lesions Skin tags or tail-like appendages...

Why Does He Have Such a Dry Mouth?

PediatricEducation.org — Mon, 13 Jul 2009 00:01:48 +0100

Discussion Saliva is produced mainly from the submandibular salivary glands (70-75%) and the parotid gland (20-25%). It functions to protect the mouth, aid digestion, maintain tooth integrity and facilitate chewing, swallowing and speech. Dry mouth or xerostomia especially in children is usually a temporary condition often associated with dehydration or mouth breathing. But it can be a more chronic condition that can affect quality of life and overall health. Patients with chronic xerostomia may stop eating certain dry or sticky foods which may lead to malnutrition. It can also change taste, and impair chewing, swallowing, and swallowing. It can also cause fissures in the skin or oral mucosa and contribute to dental caries and other oral infections. Children with multiple medical problem...

What Are the Presenting Problems of Staphylococcus in Neonates?

PediatricEducation.org — Mon, 06 Jul 2009 01:01:43 +0100

Discussion Staphylococcus sp. are gram-positive, catalase-positive cocci that cluster when viewed microscopically. There are 17 species indigenous to humans and 13 colonize humans. Staphylococcus aureus is the only species that produces coagulase. Staphylococcus sp. can be found in almost any environment including high salt, low oxygen, high heat and low moisture. Coagulase-negative Staphylococcus sp. are so common that newborn infants are colonized by 2-4 days of life usually with S. epidermidis and S. haemolyticus. Staphylococcus aureus produces many infections especially pneumonia and surgical wound infections. Humans can be colonized with it especially in mucous membranes and the perineum and axilla. Those with nasal carriage can also transiently carry the organism on their hands, thu...

Can I Prescribe a Cephalosporin If He Is Allergic to Penicillin?

PediatricEducation.org — Mon, 29 Jun 2009 00:01:48 +0100

Discussion Otitis media is a common problem in pediatrics. As approximately 50% of all otitis media is viral in etiology, antibiotics in many cases are unnecessary and potentially harmful to patients. Overprescribing of antibiotics can lead to bacterial resistance in the community and potentially to allergic reactions in patients. Allergic reactions to antibiotics can be difficult to diagnose as some initial reactions may present solely as a rash. Unfortunately, many viral infections may also cause rashes. These rashes may mistakenly be associated with the antibiotic. Thus, the patient may erroneously be labeled as antibiotic allergic. On the other hand, patients who truly are antibiotic allergic may have minor symptoms the second or third time they are exposed, but then have symptoms that...

What Causes Photophobia?

PediatricEducation.org — Mon, 22 Jun 2009 12:01:11 +0100

Discussion Corneal abrasions are common problems in children that can be caused from a variety of trauma. Children’s fingernails and toys are frequent culprits along with dust particles particularly under windy circumstances. A review of treatment for corneal abrasions and a brief differential diagnosis of painful eyes can be found at: To Patch or Not to Patch, That is the Question Learning Point Photophobia is excessive light sensitivity and can be caused by a variety of entities. The differential diagnosis includes: Ophthalmological problems Glaucoma, congenital Retinitis pigmentosa Drugs Atropine Ethosuximide Mercury Infection Amoebic meningoencephalitis Aspergillosis Botulism Enrlichiosis Lyme Disease Lymphocytic Choriomeningitic Virus Measles Meningitis Onchocerciasis Parasi...

We’re Taking A Short Break

PediatricEducation.org — Mon, 08 Jun 2009 00:01:26 +0100

The next PediatricEducation.org case will be published on June 22, 2009. Thank you, Donna D’Alessandro, M.D., Curator (Source: PediatricEducation.org)

He Just Makes a Mess!

PediatricEducation.org — Mon, 01 Jun 2009 12:01:59 +0100

Discussion Meatal stenosis is a common problem. It can occur in up to 10% of circumcised boys. It is also more common in circumcised boys. This may be due to chronic irritation of the delicate tissues of the meatus caused by exposure to urine in the diaper and mechanical irritation of the diaper itself. Families may not notice the problem until the child is toilet training or afterwards because they do not witness the urinary stream and its deflection. Another potential mechanism is frenular artery damage during circumcision which results in ischemia and subsequent stenosis. The history usually includes symptoms that the urinary stream is defected upwards and is high-velocity (= long distance). There may be pain or burning with urination, blood spotted underwear, and urgency, frequency or...

What Are the Common Metabolic Causes of Urolithiasis?

PediatricEducation.org — Mon, 19 Jan 2009 08:00:00 +0100

Discussion Metabolic causes of urolithiasis are increasing. The common metabolic causes of urolithiasis in children are below along with their percentages: Hypercalciuria - 30-50%, these are radiopaque on radiographs Hyperoxaluria - 20%, these are radiopaque on radiographs Hyperuricosuria - 2-10%, these are not radiopaque on radiographs Cystinuria - <1%, these are not radiopaque on radiographs Xanthinuria - <1%, these are not radiopaque on radiographs Patients presenting with urolithiasis should have a metabolic evaluation to help determine the etiology and possible treatments. Metabolic evaluation may include the following: Serum - electrolytes, creatinine, calcium, phosphorus, uric acid, and alkaline phosphatase. Parathyroid hormone in patients with hypercalciuria, hypercal...

How Much Vitamin D is in Milk?

PediatricEducation.org — Tue, 13 Jan 2009 07:58:58 +0100

Discussion Vitamin D is an important vitamin for bone formation and mineral homeostasis. Vitamin D deficiency can cause hypocalcemia, hypophosphatemia, osteomalacia, rickets and tetany. Deficiency is caused by inadequate dietary intakes of Vitamin D, inadequate exposure to sunlight or patients with fat malabsorption or renal disease. Sunscreen blocks sunlight and an SPF (sun protection factor) of 8 blocks 95% of the sun, so there needs to be a careful balance between over- and under- sun exposure. Adequate sunlight exposure for infants is considered 30 minutes/week clothed in a diaper only, or 2 hours/week fully clothed but without a hat. 25-hydroxy Vitamin D (calcidiol) is the best indicator of Vitamin D status. For a review of the production of Vitamin D, click here. Learning Point ...

What is Mauriac Syndrome?

PediatricEducation.org — Mon, 05 Jan 2009 08:00:00 +0100

Discussion Patients with type 1 diabetes mellitus may have growth failure for many reasons including insulin deficiency, poor glycemic control, concurrent autoimmune diseases, and decreased caloric intake and/or eating disorders. Autoimmune diseases that are more common include Addison's disease, autoimmune gastritis, celiac disease and hypothyroidism. Prior to treatment with long-acting insulin, delays in growth and sexual maturity were common but generally modest. Even today with good treatment, patients may have subtle abnormalities of growth (both weight and height) due to abnormalities of the IGF-1 and growth hormone axis. Learning Point Mauriac syndrome is a severe form of growth retardation seen in patients with poorly controlled type 1 diabetes mellitus. It is characterized by g...

What is the Differential Diagnosis of Torticollis?

PediatricEducation.org — Wed, 24 Dec 2008 11:41:02 +0100

Discussion Torticollis or wry neck is a clinical sign and symptom where there is a lateral head tilt and chin rotation toward the opposite side. In infants, congenital torticollis caused by a contracture of the sternocleidomastoid muscle and is the most common cause. It is usually successfully treated with stretching exercises. Common causes of acquired torticollis in older children include cervical adenitis and viral myositis. History and physical examination are important in evaluating the potential causes. A definitive history of trauma with obvious muscle spasm in the neck and shoulder girdle and normal neurological examination would most likely warrant stretching and anti-inflammatory medication. A patient with obvious viral syndrome complaints and a normal neurological examinat...

How Far is 10,000 Steps?

PediatricEducation.org — Wed, 24 Dec 2008 11:41:02 +0100

Discussion Obesity is an increasing major problem in the United States. Its complications are numerous including heart disease, diabetes and musculoskeletal problems. Historically in the U.S. when more jobs were very physical, people could get their exercise simply by doing their daily work. This is still true today in parts of the world where carrying water, gathering firewood, doing laundry, building and hunting are daily activities. It is estimated that most adults only walk about 1,000-3,000 steps/day in their daily life. At 2000 steps per 1 mile this is only 0.5-1.5 miles/day. Therefore people need to walk more or do other types of exercise in their daily life to get their necessary exercise. For those looking to reduce weight, 3,600 calories needs to be expended to lose one pound (...

200th Case for PediatricEducation.org!

PediatricEducation.org — Tue, 16 Dec 2008 08:00:00 +0100

We are pleased to announce that the case today is PediatricEducation.org's 200th case! Over the past 4 years, we have tried to offer a breadth of cases, which have aggregated into an unstructured curriculum of pediatric topics that closely parallels the structured curriculum of a pediatric residency, fellowship and continuing medical education programs. We appreciate your continued patronage. As always we are looking for suggestions for new cases, ideas to improve the digital library and we would also like to hear about how you are using the cases for self-education or teaching of students. Please send your comments to: http://www.pediatriceducation.org/sendcomments Respectfully yours, Donna M. D'Alessandro and Michael P. D'Alessandro Curators, PediatricEducation.org (Source: Pediatri...

How Common Are Subgaleal Hematomas?

PediatricEducation.org — Tue, 09 Dec 2008 09:33:56 +0100

Discussion Bleeding into the soft tissues of the head is a common problem associated with birth and usually does not require intervention. These include: A caput succedaneum is localized serosanguineous edema of the scalp that occurs between the skin and aponeurosis of the scalp. These swellings can cross suture lines and are usually due to pressure from the pelvis, uterus or vagina. A subgaleal or aponeuneuroic hematoma occurs between the aponeurosis of the scalp and the periosteum of the bone. The galea aponeurotica occurs from the occiput to the eyebrows and laterally to the temporalis fascia. It therefore can cross suture lines and is a large potential space where hemorrhage can occur. Subgaleal hematomas usually occur due to shearing of emissary veins between the intracranial venous ...

Are Leukotriene Modulators Effective for Treating Atopic Dermatitis?

PediatricEducation.org — Mon, 01 Dec 2008 08:00:00 +0100

Discussion Atopic dermatitis is a common skin condition that occurs in 10-15% of children. It is chronic, relapsing and has an immunological basis but the exact etiology is unclear. The clinical presentation varies from mild to very severe. In acute presentations the skin can have erythematous papules and/or vesicles that overly erythematous skin. There are frequently excoriations and erosions. In subacute presentations there will be erythema, excoriations and scaling of the skin. In chronic presentations the skin will have progressed to having thick plaques of skin, lichenification and/or fibrotic papules. One recent study found that childhood atopic dermatitis increased the likelihood of childhood asthma, asthma persisting into middle age, and new-onset asthma in later life. Learnin...

What Are the Genetics of Cleft Lip and Palate?

PediatricEducation.org — Tue, 25 Nov 2008 09:37:25 +0100

Discussion Patients with clefting often need the services of a multispecialty team of providers. Each child is unique and may need some or more specialists including speech and audiology, nutrition, surgery (otolaryngology, plastic, dental/orthodontics), psychiatry/psychology, social work, and genetics. Problems associated with cleft lip and palate include: Dental and orthodontia problems Feeding difficulties Hearing loss - most commonly conductive Language disorders - expressive and receptive language Speech disorders - articulation, phonation and resonation disorders commonly caused by velopharyngeal insufficiency Obstructive sleep apnea Psychosocial problems Surgical challenges to repair Surgical complications Treatment for other problems associated with genetic syndromes Weight ...

What Do I Have To Be Worried About With Neonatal Lupus?

PediatricEducation.org — Mon, 17 Nov 2008 08:00:00 +0100

Discussion Neonatal lupus erythematosus occurs in 1 of every 20,000 live births, and is caused by passive transfer of maternal antibodies to the fetus. About 50% of patients with neonatal lupus have mothers who are asymptomatic and the other 50% occurs in mothers with systemic lupus erythematosus or Sjögren syndrome. In a prospective study of mothers with infants with neonatal lupus, the mothers themselves who were asymptomatic or had an unidentified autoimmune syndrome usually did not progress to have other rheumatic diseases. Learning Point The clinical manifestations of neonatal lupus include: Cardiac problems - complete or incomplete congential heart block, but also carditis or myocarditis Skin problems - annular erythematous plaques with a small amount of scale, telangectasia...

What Causes Elevated Amylase?

PediatricEducation.org — Thu, 06 Nov 2008 08:00:00 +0100

Discussion The eating disorders bulimia and anorexia can occur together and their general features are listed below. Patients with anorexia nervosa refuse to maintain their body weight at or above a minimally normal weight for age and height (basically less than 85% of expected). They have an intense fear of gaining weight or becoming fat, even though they are underweight. They also have a distorted view of their own body weight or shape and often deny the seriousness of being underweight. For women who are postmenarchal, amenorrhea often occurs. Patients with bulimia nervosa have recurrent episodes of binge eating. A binge episode is eating an amount of food that is larger than most people would eat during a similar amount of time or similar circumstances. Patients eat this over a discr...

What Are the Complications of Duchenne Muscular Dystrophy?

PediatricEducation.org — Tue, 04 Nov 2008 12:54:59 +0100

Discussion Duchenne muscular dystrophy is a progressive, muscle-wasting, lethal disease that affects about 1 in 3500 boys. It is an X-linked recessive disorder with ~1/3 of patients having a spontaneous mutation. The genetic abnormality causes an absence or marked deficiency in the quantity of dystrophin protein in muscles. Muscle cells without dystrophin are more easily damaged during contraction with muscle inflammation, necrosis and fibrosis occurring. Patients classically have proximal muscle weakness (neck flexor, anterior abdominal, hip and shoulder girdle muscles) that presents usually by late preschool/early school-age. This is associated with a greatly elevated muscle creatinine phosphokinase level. Over ime, patients become weaker and lose the ability to ambulate between 7-12 ye...

How Do I Handle an In-flight Emergency?

PediatricEducation.org — Mon, 27 Oct 2008 08:00:00 +0100

Discussion Estimates of in-flight emergencies vary because there currently are no consistent standards for measuring them. Estimates range from 0.003% to 0.0005% (i.e. 1/333-1900 flights per year). Based on studies from the United States this translates into 13-33 emergencies/day. Luckily most in-flight emergencies are not serious and most do not require evaluation or treatment by ground personnel. Overall, vasovagal episodes such as dizziness, fainting or near fainting and hyperventilation are the most common. The most serious overall are cardiac, neurological and respiratory problems. Estimates of in-flight deaths in the United States are 21-72/year with most being elderly passengers and are attributed to cardiac or pulmonary problems. One study of pediatric in-flight emergencies f...

What Is The Differential Diagnosis of Hepatomegaly?

PediatricEducation.org — Tue, 21 Oct 2008 12:16:35 +0100

Discussion Liver masses in children include primary liver cancer, metastatic cancer from other sites, cysts and inflammatory masses. Primary liver cancer only constitutes 1-2% of all pediatric malignancies. Primary liver malignancies in infants and young children usually are caused by hepatoblastoma. In older children hepatocellular carcinoma is the most common. For intermediate ages both are common along with transitional cell tumors and primary sarcomas. Other malignant liver tumors include angiosarcoma, biliary rhabdomyosarcoma, undifferentiated sarcomas and rhabdoid tumor. Benign liver tumors include adenoma, focal nodular hyperplasia, infantile hemangioma, mesenchymal hamartoma and teratoma. Primary hepatic sarcoma is rare with the outcome depending on tumor resection, sensitivity ...

What Are the Most Common Food Allergies?

PediatricEducation.org — Mon, 13 Oct 2008 07:00:00 +0100

Discussion Food allergies are relatively common but it can be difficult to tease out if it is a true allergy, a food intolerance or is actually something else. Risk factors that increase the likelihood of food allergy include: Reactions that occur minutes to hours of the ingestion Accidental ingestion of same food that produces the same symptoms Onset of symptoms as an infant or young child Close family history of other allergic diseases such as allergic rhinitis, asthma, atopic dermatitis or food allergies The suspected food is known to be higher risk for producing allergic reactions Children with a possible food allergy may receive testing by skin-prick, patch testing or RAST (radioallergosorbent testing). RAST is a blood test that has a high sensitivity but has only ~50% specificity...

What Medications Are Recommended for Adolescents Who Are Quitting Smoking?

PediatricEducation.org — Tue, 07 Oct 2008 12:43:17 +0100

Discussion Tobacco use is a pediatric problem. In 2006, ~3.3 million adolescents between 12-17 years currently used tobacco products and 2.6 million were current cigarette smokers. Each day, ~ 4,000 adolescents and children < 18 years of age smoke their first cigarette. Unfortunately, nicotine dependence is established rapidly and many children and adolescents go on to continue to smoke. Counseling helps adolescents quit and continue to remain abstinent. Adolescents enrolled in tobacco cessation programs are 2 times more likely to quit and remain abstinent. Pediatric health care providers should discuss parental smoking as well as part of routine care, as children and adolescents benefit because of decreased second hand smoking exposure. Treatment of patients willing to quit consist...

Curators Note: Evidence-based Medicine Information Added to Each Case

PediatricEducation.org — Mon, 06 Oct 2008 07:00:00 +0100

Beginning October 6, 2008, each case in PediatricEducation.org will now include evidence-based medicine information in the To Learn More section. The National Guideline Clearinghouse is an automated search on the case topic. The Cochrane Database of Systemic Reviews does not allow automated searching so a link to its main search page is used instead. We hope you find this new feature helpful. Donna M. D'Alessandro, M.D. and Michael P. D'Alessandro, M.D. Curators, PediatricEducation.org (Source: PediatricEducation.org)

How Should Bike Helmets Be Fitted?

PediatricEducation.org — Mon, 29 Sep 2008 07:00:00 +0100

Discussion Bicycling and other wheeled sports are great exercise and fun family activities. But to maintain the fun, safety must be a consideration. There are ~540,000 emergency room visits for bicycle injuries every year. Of those visits, ~67,000 involve head injuries and ~27,000 require hospitalization. About 770 people died from bicycle injuries in 2006, mainly from head injuries. It is estimated that a bicycle helmet could prevent 45-88% of brain injuries. Unfortunately many people do not wear a helmet or it is improperly fitted. In a cross-section study of 8 communities in Texas in 2002 that evaluated helmet use for wheeled activities, only 13.6% of people observed wore a helmet. Of those that wore a helmet, only 72.5% wore them correctly. Wearing of the helmets was dramatically i...