Clinical Problems In Childhood and Adolescence - …fcm.ucsf.edu/sites/fcm.ucsf.edu/files/017...
Transcript of Clinical Problems In Childhood and Adolescence - …fcm.ucsf.edu/sites/fcm.ucsf.edu/files/017...
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Shannon Thyne, MDUCLA Department Of
Pediatr ics
Clinical Problems in Childhood and Adolescence
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A very little bit… on Growth and Development
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Normal Growth in Children
Weight• Weight loss in first few days of life– 5-10%• Regain birth weight by DOL #10• Double birth weight by 4-5 months• Triple birth weight by 1 year• Quadruple birth weight by 2 years• Daily weight gain
• 10-30g for first 3 months• 15-20g for remainder of 1st year
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Failure to Thrive
Generally described as <3%tile for weight or decrease over 2 major percentiles
Psychological, biological, environmental causes• Stress• Genetic syndrome/FAS• GI abnormality• Low intake
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Puberty
Girlso Mean age of menarche decreasing in the US (12.53 in 1988-94
compared with 12.34 in 1999-2002) African American (12.06 years) Mexican American (12.09 years) Caucasian (12.52 years) [J.Peds, 2005]
o Development of secondary sex characteristics prior to age 7 is considered precociouso Range 7-13 with lower range used for AA girls
o Causal factors suggested: increased BMI, increased animal fat intake, exposure to endocrine-disrupting chemicals (BPA, phthalates)
Boys African-American and Caucasian males mature at comparable ages Sexual development before age 9 is considered precocious
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Puberty
Girls• Breast development pubic hair development growth
spurt menarche
Boys• Increased testicular volume pubic hair development
penile enlargement growth spurt
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Developmental Problems – Speech and Language
Speech and language delay - most common• Often constitutional but can indicate bigger issues such as
autism Language delay warnings
• 3 yo – not using short phrases• 4 yo – no 3 word sentences• 5 yo – not following 2 part commands
Screening• Hearing screen at birth• 9 months – screen via ASQ• 24 months – M-CHAT (Modified Checklist for Autism in
Toddlers)
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Growth and Developmental Delay
Fetal Alcohol SyndromeFragile XFailure to Thrive
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Fetal Alcohol Syndrome
Common reason for poor growth
Cognitive delay Behavior problems No known safe
level of alcohol consumption
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Fragile X Syndrome
1/400 carry gene; Males > Females
1/2000 males affected 1/4000 females
Low IQ, behavior problems
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Childhood Deaths
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Childhood Deaths: Think ACCIDENTS!
46% decrease in accidental deaths in the past 20 years due to improved safety measures.
Accidental death causes1. MVA2. Falls3. Poisoning4. Drowning5. Fires/burns
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Childhood Deaths-all causes
0-1 years:• Developmental and genetic
conditions present at birth • Sudden Infant Death Syndrome
(SIDS)• All conditions associated with
prematurity/low birth weight1-4 years:
• Accidents • Developmental and genetic
conditions present at birth • Cancer
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Childhood Deaths - all causes
5-14 years: • Accidents • Cancer • Homicide
15-24 years: • Accidents • Homicide • Suicide
Most deaths > age 5 are PREVENTABLE!
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Sudden Infant Death Syndrome
SIDSRisk factors
prone sleeping positionsmoke exposuresoft beddingprematurityperinatal drug exposureAfrican/Native American
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Sudden Infant Death Syndrome
• SIDS– prevention works!• Sleeping in same room with adults• Pacifiers when falling asleep• BACK TO SLEEP!!!
Back to Sleep Campaign introduced 1992-4Death Rates (per 100,000)
1995 1998 2001 current87 71 55 40’s
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Other Common Issues in Primary Care
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Colic
DEFINITION:Healthy, well fed infant with paroxysms of crying lasting >3 hours per day and occurring more than 3 times per week.
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Colic
Does not occur in the first days of lifeMost affected infants develop
symptoms by 2 weeks of ageMost episodes occur early in the
eveningMost infants are colic-free by 3 months
of life
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Colic
Treatment Rhythmic Rocking Encourage sucking Swaddle, bundle, cuddle DON’T medicate Be patient, and realize that it will go away
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Iron Deficiency Anemia
• Common in US children ages 12-36 months (5.5% with Hgb <11.0)
• Dietary Iron• 8-10 mg iron must be consumed each day• 2-3 times more iron is absorbed from human milk
than formula• breast milk or iron fortified formula is recommended
for the first year of life• An additional source of iron should be provided at 4-6
months of age
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Iron Deficiency Anemia
Most common between 9-24 months of ageCows milk often the culprit
• little bio-available iron• replaces food with higher iron content• inhibits iron absorption• can cause GI bleeding
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Iron Deficiency Anemia
Response to oral iron administration• reticulocytosis- 48-72 hours• increase in hemoglobin- 4-30 days
(increase in hemoglobin by 1 gm/dl after 1 month of therapy)
• increase in iron stores- 1-3 months
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Lead Poisoning
Contributes to iron deficiency anemia Chelation very rare in areas without lead paint
• East Coast higher• Currently less than 2% of kids have levels >10 mcg/dl
Screen 9-72 months; more for high risk NO SAFE LEVEL
• Evidence of decreased cognitive function • Recommendations for >10• Recheck in 3 months if elevated
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Vitamin D Supplementation
• Old recommendation: Breastfed infants should start on vitamin D supplementation at 400 IU per day (AAP 2003)
• New recommendations: 400 IU vitamin D supplementation for ALL infants and children beginning in the first few days of life
• Supplementation can be stopped if taking >1000ML formula daily >1 year and taking Vit-D fortified milk at
>32oz/day
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Vitamin Supplementation
Summary:Vitamin D supplementation at 400 IU daily
starting at birth (goal about 800 total)Change to Vitamin D plus iron supplementation
at 4-6 monthsContinue both until 5 yearsConsider ongoing Vitamin D supplementation
(along with Calcium ) for older children and adolescents at 400-800 IU/day
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Breath Holding Spells
Common phenomenon in healthy children
Usually occurs between 6-18 months of age
Family history in 23-30% Onset before the age of 5 years
old Breath is held on exhalation
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Breath Holding Spells
Sequence of events in Breath Holding Spell• precipitating event• child cries or becomes upset• noiselessness, exhalation,
cessation of breathing• color change, hypotonia• in severe cases, seizure
activity• limpness, return of
consciousness
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Breath Holding Spells
Types of Breath Holding spells• cyanotic• pallid
Frequency• once a year to several a day• peaks at age 2 years
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Breath Holding Spells
Differential Diagnosis• Seizures• Syncope• Prolonged QT
Prognosis• Excellent if no underlying process
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Enuresis
Incidence 5 year olds: 15-20% 10 year olds: 5% 15 year olds: 1-2%
Annual spontaneous cure rate is 15%Nocturnal enuresis common in malesDiurnal enuresis more common in
females
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Enuresis
Etiology1. Family history2. Bladder Capacity3. Developmental lag4. Sleep level5. Psychological factors6. Inadequate ADH secretion
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Enuresis
Uncomplicated• Nocturnal symptoms• Normal physical examination• Negative UA and urine culture
Complicated• History of voiding dysfunction• Abnormal neurologic or abdominal exam• History of UTI• Positive UA
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Enuresis Interventions
Should be age appropriate Initiated only after full work-up reveals no
abnormalities 3 years:
• Self awakening hints• Good bedtime habits• Empty bladder• Limit fluids• Praise for dry mornings
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Enuresis-- Interventions
6 years:• Self awakening tips• Motivational techniques
8 years:• Enuresis alarm• Drugs intermittently for special
events 12 years:
• Enuresis alarm• Drugs continuously for 2-6
months
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Non-Infectious Abdominal Complaints
Acute ScrotumAcute AbdomenIntussusception
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Acute Scrotum
History• Age, onset of symptoms, prior trauma, associated
findings (rash, fever, etc.)
Physical Exam• Cremasteric reflex• Appearance of scrotum• Palpation
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Acute Scrotum
Differential diagnosis of painful, enlarged testisTesticular torsionTorsion of the appendix testisTraumaEpididymitisTumor
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Testicular Torsion
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Testicular Torsion
Anatomic deformity Typical history
• Acute onset, with nausea and vomiting
• While active, at rest, or after trauma
• Often history of similar events, although less severe
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Testicular Torsion
Physical findings• Scrotal edema, erythema, high riding testicle• Entire testicle is tender (as opposed to “blue
dot” and focal tenderness of appendix torsion)
• Spermatic cord “knot”• Absent cremasteric reflex
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Testicular Torsion
Radiologic studies• Decreased blood flow on nuclear scan
Treatment• Surgical emergency• Detorse the affected testicle and anchor
both sides
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Intussusception
Invagination/telescoping of proximal intestine into the adjacent bowel
Often a “lead point” in Peyer’s Patch
Most common cause of intestinal obstruction between 3 months and 6 years of age
Etiology unknown in 95%
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Intussusception - Definition
Presentation: crying with severe, colicky (due to peristaltic rushes) abdominal pain, flexion of the knees and hips
The initial pain subsides with infant quite comfortable between episodes
Over time: increasing frequency of pallor, diaphoresis, and increasing pain may occur
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Currant Jelly Stool
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Intussusception: Plain Film
Mass (M)and dilated Bowel loops
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Intussusception: Barium Enema
“Coiled Spring”
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Intussuception: Management
ResuscitationEnema Reduction
• Barium/AirSurgery
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Intussusception: Prognosis
Untreated intussusception in infants is almost always fatal
Recurrence is rare at >24 hours post reduction
Mortality rate rises rapidly after 24 hours, especially after the 2nd day
Spontaneous reduction during preparation for operation is not uncommon
Long terms complications are few
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Rotavirus Vaccine & Intussusception
ACIP & AAP in 1998 recommended RRV-TV for routine childhood immunization of US children
From Sept 1, 1998 - July 7, 1999: 15 cases of intussusception among infants who had received RRV-TV
Several studies also noted higher incidence rate within the 1st week after RRV-TV
CDC recommended suspending routine vaccination 2006 new formulation approved; currently in use with
no increase in intussusception noted Now 2 formulations RotaTeq and Rotarix
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Non-Infectious Rashes
Idiopathic Thrombocytopenic PurpuraHenoch Schonlein Purpura
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Idiopathic Thrombocytopenic Purpura (ITP)
Common acquired bleeding disorder in children < 10 years old
Manifestations:• platelet count < 150,000• normal bone marrow• purpuric rash• absence of other causes of
thrombocytopenia
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ITP
Clinical signs and symptoms Petechiae, purpura,
epistaxis, hematuria Preceding viral illness Absence of
hepatosplenomegaly
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ITP
Laboratory studieso Thrombocytopeniao Mild anemia sometimeso Platelets may be largeo Normal bone marrowo Normal peripheral blood
smear
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ITP
Natural history of ITP• Most cases of ITP in children are acute• 75% spontaneously remit within 6 months• Mortality is less than 1% (CNS bleeds)
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ITP
Management Wait and see (with good precautions) Steroids Concern for use if malignancy not ruled out cause a rapid rise in platelet count
IVIG similar rise in platelet count as compared to steroids no need for bone marrow
Anti-D (winrho) Coats normal red cells and helps block spleen’s
destruction of platelets
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Henoch Schonlein Purpura (HSP)
IgA mediated small vessel vasculitis
Generally in children between 2-12 years of age
75% with preceding URI
Boys 1.5/Girls 1.0
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HSP
Clinical Manifestations• Purpuric rash (100%)• Abdominal pain (50%)• Scrotal edema in boys • Other edema: periorbital, distal extremities• Arthritis (knees, ankles, hands)• Hematuria (up to 80%)• Nephritis (20-30%)
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HSP
Treatment:NSAIDS SupportiveOccasional cytoxan for severe kidney disease
Although very rare, renal failure is the most common serious complication
Steroidssoft tissue swellingscrotal swellingabdominal pain
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Altered Mental Status
Seizures (febrile and nonfebrile)ALTE (now Called BRUE) Brief Resolved Unexplained Event
DKA IngestionsShaken Baby Syndrome
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Febrile Seizures
Typical Febrile Seizure• Generalized, tonic-clonic• <15 minutes duration• Child 6 months-5 years old• (peak 15-18 months)• One seizure in 24 hour period
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Febrile Seizures
Atypical/Complex Febrile Seizure:• Prolonged >15 minutes• >1 seizure in 24 hours• Focal • Todd’s Paralysis after the
seizure qualifies it as complex
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Febrile Seizures: Facts and Stats
Occur in 3-4% of all children 25-30% of kids with febrile seizures will
have a second and 50% of those with a second will have a 3rd
FS do NOT cause MR, CP, learning disorders
FS do not cause epilepsy or afebrile seizures
However….
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Febrile Seizures: Facts and Stats (cont.)
Family history of epilepsy, preexisting neurologic disease, and the history of a complex febrile seizure correlate with increased incidence of epilepsy later in life
If all 3 of the above exist, increased risk of seizure disorder to 10-15%, up from baseline of 0.4% in population
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Febrile Seizure: Work-up
STOP! Work up the FEVER• 73% of the time it’s OM, URI, pharyngitis, viral exanthems• Fever workup is the most important part
If the child returns to baseline status, no seizure work-up needed
Blood Studies (lytes, Ca, Mg, Phos, glucose) are NOTroutinely recommended
EEG NOT routinely recommended LP NOT routinely recommended
• Consider in child with meningeal symptoms• Consider if not vaccinated for Hib, S.pneumo or pretreatment with
Abx.
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Febrile Seizure: Treatment
Treat the cause or the feverOkay to consider RTC
acetaminophen or ibuprofen for fevers but not as prevention of seizures
In children with multiple recurrences, consider rectal diazepam
Neurology referral not routinely needed
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Childhood Asthma
Childhood asthma is (still!) on the rise #1 cause of school absences # 1 admitting diagnosis 7-16% of kids have asthma (California, 2013)
15.2% prevalence for African American children 9.4% for Caucasian children
Higher in inner city, low income kids Majority diagnoses < age 5 Often associated with allergies
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Childhood Asthma
Management of exacerbations• Albuterol – nebulized and MDI have same efficacy• Ipratroprium Bromide – adjunctive to albuterol in acute
management but not in daily maintenance• Magnesium Sulfate – may be helpful in patients not
responding to albuterol treatments• Systemic steroids – should be initiated when not
responsive after initial albuterol treatments or when admission is being considered• Oral dexamethasone well tolerated
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Asthma
Inhaled corticosteroids are safe and effective for children!
New guidelines focus on functional status as well as baseline diagnosis
Rule of 2’s• Daytime symptoms >2x weekly• Nightime symptoms >2x monthly• Exacerbations >2x yearly If yes to any of the above, need ICS for 1-3 months and
then reassess!
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Questions?