CONTENTSlandon/PedsCurric/Curriculum.doc · Web viewSpecific signs/symptoms – otorrhea, otalgia. Decreased hearing. Diagnosis Best done with a pneumatic otoscope. Usually a symptomatic

COMMON PEDIATRIC PROBLEMS Caren Mangarelli, M.D.

Special Thanks to Dr. Joel Schwab, Residency Director, Dept. of Pediatrics, University of Chicago Children’s Hospital.

CONTENTS

1. Acute Gastroenteritis

2. Acute Otitis Media

3. Otitis Media with Effusion

4. Anemia

5. Bronchiolitis

6. Constipation/Encopresis

7. Croup

8. Dentistry

9. Nocturnal Enuresis

10.Sleep Problems

11.Strep Pharyngitis

12.The Pink or Red Eye

13.Toilet Training

ACUTE GASTROENTERITIS

Characterized by rapid onset of diarrhea with or without vomiting, fever and abdominal pain. Diarrhea is defined as frequent, loose, unformed liquid stools. Most cases caused by viral or self-limited bacterial disease.

Important History

1. Recent travel.2. Known sick exposures.3. Recent use of antibiotics.4. Daycare attendance.5. Previous state of health (ie. Immunocompromised or not).6. Presence of blood in stool.

Physical Exam

Need to determine if child dehydrated and estimate extent of dehydration.1. Weight is most accurate measure of percent dehydration, but often a recent previous

weight not available.2. Mild dehydration (3-5%) - often has no changes in vitals nor physical exam.3. Moderate dehydration (6-10%) – increased heart rate, decrease in tears and urine

output, slightly prolonged capillary refill, mucous membranes tacky. Child generally irritable, but consolable.

4. Severe dehydration (>10%) – child becoming lethargic with significant decrease in urine output. Skin is cold and clammy, mucous membranes are dry and child producing no tears.

Work-Up

For the majority of patients, there is no need to do a stool culture, UA nor serum electrolytes. If stool is bloody or something suspicious in history, consider sending for bacterial culture. If child severely dehydrated, would send serum electrolytes.

Treatment

1. Oral rehydration is the preferred treatment of fluid and electrolyte losses for children with mild to moderate dehyration.

2. OTC rehydration fluids that most closely resemble the sodium, potassium and osmolality losses from diarrheal stools are Pedialyte and Infalyte.

3. Soft drinks, fruit drinks and sports drinks should be avoided because they lack electrolytes and are hyperosmolar which can induce more diarrhea.

4. If child has diarrhea, but is not clinically dehydrated, they should continue to be fed age appropriate diets and the type of oral fluids they take in is less important.

5. The child who is dehydrated should be rehydrated first and restarted on age appropriate diet as soon as possible.

6. Net balance of nutrients, rather than the number of stools should be the primary concern. Suboptimal absorption of some food is better than no absorption of no food. Focus on complex CHO foods like rice, wheat noodles, potatoes, bread, cereal; also lean meats, veggies, yogurt, bananas. Classic BRAT diet is well tolerated, but low in energy, protein and fat.

7. If child is also vomiting, can often still achieve rehydration orally if give sips or teaspoons of fluid on a frequent (every 15 min.) basis.

8. Encourage continuation of breastfeeding – is the best choice.9. Most children need no reduction in lactose (unless severe illness) – reduced lactose

may mean reduced calorie diet.10. Many Mexicans use rice-water. Is actually not a bad choice. Rice is well absorbed.11. As a general rule, pharmacologic agents should not be used to treat acute diarrhea

- Anti-motility agents like Immodium AD and Lomotil contraindicated in young children.

- Pepto-Bismol not recommended, but further studies may demonstrate role.- Adsorbents (Kaopectate) not recommended because no proven benefit (but

probably not harmful).- Lactobacillus containing compounds have shown some benefit, but inadequate

studies.

References:

1. AAP Practice Parameter on the Management of Acute Gastroenteritis in Young Children, Pediatrics, 97: 424-436, 1996.

2. MB Cohen, Non-Antimicrobial Therapy of Diarrheal Disease: Earth, Brine, and Fiber, AAP CME Seminar, March, 2001.

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ACUTE OTITIS MEDIA

Acute otitis media is a very common pediatric disease and approximately 80% of children will have one episode by three years of age. It is defined as rapid onset of signs and symptoms of acute infection within the middle ear. The highest incidence is between 6-18 months of age during the winter season. Acute otitis media is the most common reason for outpatient antimicrobial treatment in the United States.

Risk Factors

1. Attendance at daycare.2. Altered immune system.3. Exposure to smoke.4. First episode before 6 months of age.5. Family history.6. Anatomical variations – cleft palate, Down syndrome, craniosynostosis.7. Not being breastfed – three months needed for any protective effect.8. Native American or Alaskan Eskimo

9. Early use of antibiotics – increase in AOM in countries where antibiotics readily availale.

10. White/Male.

Pathogenesis

Normally the eustachian tube equalizes pressure between the middle ear and the atmosphere, protects the middle ear from nasopharyngeal secretions and bacteria, and drains secretions from the middle ear into the nasopharynx. If the eustachian tube is obstructed, bacteria may proliferate in the middle ear space. In addition, obstruction may lead to increased negative pressure within the middle ear and “sucking” of pathogens into the middle ear space. Obstruction is often caused by an upper respiratory viral infection which results in congestion or inflammation of the respiratory mucosa. There may also be functional obstruction due to the fact that in infants the eustachian tube is shorter, wider and more horizontal, and the supporting structures are underdeveloped. Finally, there may be extrinsic obstruction due to tumors or enlarged lymphoid tissue.

Microbiology

1. Streptococcus pneumoniae (25-50%, mean 38) – least likely to resolve spontaneously, increasing incidence of antibiotic resistance.

2. Non-typeable Hemophilus influenza (15-50%, mean 27) – up to 55% beta-lactamase producers, associated with conjunctivitis (conjunctivitis-otitis syndrome).

3. Moraxella catarrhalis (2-15%, mean 10) – up to 100% beta-lactamase producers and also associated with conjunctivitis.

4. Group A Streptococcus (2-3%)5. Viral (<10%) – often associated with bacterial superinfection.6. Others – Staphylococcus aureus, Mycoplasma, Chlamydia – uncommon.7. Newborns have increased incidence of gram negative organisms and GBS.8. If tympanostomy tubes, can develop acute otitis caused by organisms associated with

otitis externa (Staph aureus, Staph epidermis, Pseudomonas).9. Nasopharyngeal cultures are usually not indicated. They are sensitive, but not

specific. They are more helpful for monitoring antibiotic susceptibility patterns.

Symptoms

1. Often preceded by URI.2. Usually sudden onset.3. Nonspecific signs/symptoms – fever, irritability, anorexia, and vomiting.4. Specific signs/symptoms – otorrhea, otalgia.5. Decreased hearing.

Diagnosis

Best done with a pneumatic otoscope. Usually a symptomatic child with a red, bulging, poorly mobile tympanic membrane. Often overdiagnosed due to relying solely on color,

past history, parental pressure or rechecking too soon after previous treatment. Tympanometry often useful for confirming the presence of fluid previously identified with pneumatic otoscope. Tympanometry has a better negative predictive value and about 50% of abnormal tympanograms will have normal middle ears. Tympanocentesis was previously performed with a higher frequency. Today typically done only as part of a study or in children with immunodeficiency syndromes or treatment failures in order to identify an organism with sensitivities.

Management

1. Somewhere between 60-80% of cases will resolve spontaneously, but there is no clinical means to distinguish between those that need to be treated with those that don’t. It is generally accepted that antibiotics decrease the length of symptoms in the short-term, but there is no proven decreased incidence of recurrence nor otitis media with effusion in the long-term. Antibiotic treatment is always associated with some harms or side effects.

2. Amoxicillin is still considered the first antibiotic of choice. Need to consider high dose (80-90mg/kg/day) in children with risk factors like daycare attendance or recent antibiotic treatment.

3. If otitis associated with conjunctivitis, need to use a beta-lactamase resistant antibiotic.

4. One dose of IM Ceftriaxone has been shown to be effective, but may need 2-3 doses for resistant Strep pneumo.

5. Second –line therapy includes high dose Augmentin, Omnicef (Cefdinir), Vantin (Cefpodoxime), Cefzil (Cefprozil), or Ceftin (Cefuroxime axetil).

6. Macrolides not the best choice due to Strep pneumo as well as H. flu resistance.7. Duration of treatment is variable and data not conclusive whether 5 or 7 days as good

as 10 days.8. Ibuprofen and paracetamol have been shown to reduce pain in short-term.9. If child is not clinically improved within 48-72 hours rechecking child is

recommended and changing the antibiotic is an option.10. Once treated the middle ear effusion usually becomes sterile, but may persist for

weeks to months, therefore rechecking has its pluses and minuses.11. Prophylactic use of antibiotics in children who have had more than 3 infections in 6

months or more than 4 in one year may decrease the frequency of AOM, but inconsistent evidence. Unfortunately, prophylaxis is a major contributor to emergence of antibiotic resistance.

Complications

Serious complications are rare, but include hearing loss, perforation, mastoiditis, intracranial abscess, sinus thrombosis, meningitis and facial nerve paralysis.

References:

1. Dowell SF, Butler JC, Grebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance – A report from the Drug Resistant Strep. Pneum Therapeutic Working Group. Ped. Infect. Dis. Journal, 1999; 18:1-9.

2. Feigin, Cherry. Textbook of Pediatric Infectious Diseases, Edition 4, Vol. 1.3. BMJ Publishing Group, Clinical Evidence Pediatrics, Issue 7, 2002.

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OTITIS MEDIA WITH EFFUSION

Defined as the presence of fluid in the middle ear without signs or symptoms of acute infection. In some instances, aspiration of the fluid may yield the presence of bacteria similar to those found in acute otitis media. Congenital or early-onset hearing loss is an accepted risk factor for delayed or impaired speech and language development. Since otitis media with effusion is often associated with a mild to moderate degree of hearing loss, most physicians have made the assumption that it can interfere with language/speech development. It is currently uncertain and unproved whether changes in hearing due to middle ear fluid has any long-term effect on development.

Risk Factors

1. Day care attendance.2. High number of siblings.3. Low socioeconomic group.4. Frequent URIs.5. Bottle-feeding.6. Household smoking.

Physical Findings/Diagnosis

1. Often an incidental finding.2. May be seen following an acute otitis media episode – may persist for weeks to

months, median duration 23 days.3. May present with decreased hearing, ear discomfort or behavioral changes.4. A pneumatic otoscope is recommended for assessing the middle ear and the presence

of fluid.5. Exam will show decreased mobility of the TM. Fluid may appear as bubbles, clear,

yellow or grayish. TM may appear thickened or opaque.6. Tympanometry can be helpful in confirming diagnosis (flat or Type B). Has a better

negative predictive value (if normal, middle ear normal).7. Otitis media with effusion often misdiagnosed as acute otitis media.

Treatment

Most people refer to the Clinical Practice Guidelines as outlined by the Agency for Health Care Policy and Research. These guidelines specifically address what to do with children ages 1-3 years. More than half the children will have spontaneous resolution of the otitis media with effusion within 3 months.

1. Antibiotic therapy – Some evidence to show faster resolution of OME with antibiotic use. No significant effect on long term outcomes. Definite adverse effects due to side effects of medication in addition to the ever increasing problem of microbial resistance.

2. Environmental risk factor control counseling.3. No evidence or inadequate evidence for use of antihistamines, decongestants or

steroids.4. After 3 months of bilateral effusion, hearing test should be performed. If greater than

20 decibel bilateral hearing loss should consider antibiotic treatment or ENT referral for myringotomy tube placement. Should evaluate speech and language development.

5. Placement of myringotomy tubes is recommended after 4-6 months of bilateral effusion with bilateral hearing deficit.

6. Adenoidectomy and tonsillectomy either alone or combined have not been proven effective for the treatment of otitis media with effusion.

7. New long-term study out of Pittsburgh by Paradise et al is evaluating long-term outcomes of children with otitis media with effusion. New evidence may show no long term detrimental effects on development.

References:

1. American Academy of Pediatrics, Practice Guideline – Managing Otitis Media with Effusion in Young Children, Pediatrics, Vol. 94, #5, November 1994.

2. BMJ Publishing Group, Clinical Evidence Pediatrics, Issue 7, 2002.3. Paradise J, Feldman HM, Campbell TF, et al. Effect on early or delayed insertion of tympanostomy

tubes for persistent otitis media on developmental outcomes at the age of three years. N Engl J Med 2001; 344:1179-1187.

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ANEMIA

Need to be aware of normal values for children of different ages in order to correctly diagnose anemia. See chart below extracted from CDC data: (chart unavailable)

Important History

1. Birth History – preterm infants have less stores and higher requirements due to accelerated growth. Normal nadir in full term infants around 3 months of age (RBC lifespan 120 days). Need to find out about any blood loss at birth.

2. Family History

3. Ethnicity/Race – Mediterranean – thalassemiaSephardic Jew, Filipinos, Greeks, and Kurds – G6PDAfrican Americans – Hgb S and C, alpha thalassemiaAsians – alpha thalassemia

4. Diet – all infants should use formula with iron. If breastfed, should supplement after 6 months. Only about 10% of iron in whole milk is available for absorption and it may cause GI bleeding and loss of iron. Also, if drinking lots of whole milk after age 1 yr., unlikely eating other foods rich in iron. Good sources of iron include cereals, greens, meats and beans. Ascorbic acid enhances the absorption of dietary iron.

5. Growth history – chronic disease6. Bleeding history 7. Pica8. Medications

Physical Examination

1. Skin – petechiae, purpura, jaundice, hemangiomas2. Enlarged liver – malignancies, extramedullary hematopoesis, chronic diseases3. Significant adenopathy – leukemias and lymphomas4. Heart rate and presence of murmur5. Extremities – radial anomalies associated with congenital anemias (Fanconi’s)6. Oral cavity – glossitis associated with B12 and iron deficiency7. Facies – frontal bossing in thalassemia8. Splenomegaly – hemolytic anemia, ALL, lymphoma, extramedullary hematopoesis9. Stool – for occult blood

Treatment/Evaluation

1. If history, physical and diet history are suggestive of iron deficiency and nothing else concerning, a therapeutic trial of elemental iron at 5mg/kg/day is advisable before further work-up.

2. Should recheck hemoglobin in one month. Should expect a rise of 50-66% of deficit.3. Should counsel regarding iron-rich diet.4. Should treat for a total of 3 months to replenish iron stores.5. If there is not a significant rise in hemoglobin or hematocrit, then consider further

work-up including:Complete CBC with differential, platelets and smearReticulocyte countTIBC and FerritinLeadHemoglobin electrophoresis.

References:

1. Oski, F., Iron Deficiency in Infancy and Childhood. NEJM, Vol. 329 No. 3:190-193, 1993.2. Bomgaars, L., Approach to the Child with anemia, UpToDate Online 10.2, 2002.

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BRONCHIOLITIS/RSV

Bronchiolitis is an acute communicable disease predominantly presenting in the first two years of life. It is characterized by both upper and lower respiratory tract disease. Symptoms include cough, coryza, fever, expiratory ronchi and wheeze, tachypnea, apnea and respiratory failure. Although the majority of cases are causes by respiratory syncitial virus(RSV), other causes include influenza, parainfluenza, adenovirus, mycoplasma and rhinovirus. Bronchiolitis is a viral disease of infancy. There is currently no evidence for a primary role for bacteria in bronchiolitis and secondary bacterial infection is uncommon.

Epidemiology

1. Most commonly occurs in infants less than 6 months of age.2. Epidemic outbreaks of bronchiolitis caused by RSV are seasonal. Most cases occur

between November and May. Lowest incidence in August.3. More common in males – male:female ratio 1.5:1.

Clinical Characteristics

1. Typically presents with initial URI symptoms which progressed to cough, respiratory distress and difficulty feeding.

2. Often accompanied by fever in first 2-4 days of illness.3. Young infants may present with apnea.4. Physical exam usually demonstrates tachypnea, ronchi, and wheezing as well as other

signs of respiratory distress.5. In the case of RSV, individuals can be infected more than once in the same RSV

season, however, subsequent infections are usually milder.

Diagnosis

1. Generally a clinical diagnosis especially in outpatient setting.2. Rapid antigen assays (DFA or ELISA) of nasal washings often used in hospital

setting with over 90% sensitivity and specificity.

Indications for Hospital Admission

1. Hypoxemia.2. Poor oral intake and dehydration.3. Respiratory distress or apnea.4. Underlying pulmonary (BPD), cardiovascular or immunologic deficiency disease.

Treatment

1. Oxygen support if needed.2. IV fluids if needed.3. Inhaled bronchodilators – improve clinical score in short term, but no consistent

evidence that they decrease hospital admission rates, length of stay or improve O2 saturation. Most people recommend trial of bronchodilators in hospitalized children for 12 hours and discontinue if no clear clinical benefit.

4. Intubation for infants and children with apnea or respiratory failure.5. No role for antibiotics nor steroids.6. No role for ribavirin except possibly in ventilated infants and children with RSV or

those with underlying heart or lung disease or immunosuppression.

RSV Immunoprophylaxis

1. Monthly IV infusions of RSVIG or monthly IM injections of palivizumab should be considered for infants and children less than 2 years of age with chronic lung disease requiring medical therapy within 6 months of the anticipated RSV season.

2. Immunoprophylaxis should also be considered in infants less than 1 year of age who were born at 28 wks GA or earlier, in infants less than 6 months old who were born between 29-32 wks. GA, and in infants less than 6 months of age who were born between 32-35 wks. GA and have risk factors for RSV, such as day care attendance or > 3 siblings.

3. Monthly immunoprophylaxis should be continued through the RSV season with regional differences taken into account.

4. Neither RSVIG nor IM palivizumab should be given to patients with cyanotic congenital heart disease.

5. If RSVIG is used, MMR and Varicella vaccines need to be deferred until 9 months after the last dose.

6. Generally, IM palivizumab is preferred due to easier administration.

References:

1. BMJ Publishing Group, Clinical Evidence Pediatrics, Issue 7, 2002.2. Welliver JR, Welliver RC, Bronchiolitis, Pediatrics in Review, Vol. 14: 134-139, 1993.3. Rakshi K, Couriel JM, Management of Acute Bronchiolitis, Archives of Disease in Childhood, Vol.

71: 463-469, 1994.4. Barr FE, Graham BS, UpToDate Online 10.2, Respiratory Syncytial Virus, 2002.Return To Table of Contents

CONSTIPATION/ENCOPRESIS

Constipation is characterized by infrequent, hard feces that are difficult and painful to evacuate. Encopresis is defined as involuntary bowel movements in inappropriate places at least once a month for 3 months in children age 4 years and older. There are two types of encopresis: retentive encopresis which is associated with constipation and overflow

incontinence, or nonretentive encopresis which is otherwise known as stool toileting refusal. We will be discussing retentive encopresis associated with constipation.

Constipation with or without encopresis is a common problem in children. It accounts for approximately 3% of outpatient pediatric visits and 25% of pediatric GI consultations. Encopresis has been reported in approximately 1.5% of children at school entry. In most cases of constipation no cause is identified.

Differential Diagnosis

Hirschsprung’s disease (agangliosis) – constipation present since birth.Cystic fibrosis.Anorectal anomalies – stenosis, fissures.Neuromuscular and spinal cord disorders.Constipating drugs.Metabolic disorders – hypothyroidism, hypercalcemia, hypokalemia.

Important History

1. Age when child potty trained.2. How often does the child have a bowel movement?3. What is the consistency and size of the stool?4. Is there pain associated with the bowel movement?5. Is there blood in the stools?6. Diet history.7. Medication history.8. Any other associated systemic signs or symptoms – enuresis, hair loss, etc.?

Physical Exam

1. Inspection of underwear for stool stains.2. Abdominal exam for masses.3. Rectal exam for changes in mucosa and stool in ampulla.4. Reflexes and strength in lower extremities and examination of spine.

Consider x-ray of abdomen, although usually not necessary.

Treatment

Treatment often varies depending on severity and chronicity of constipation. Explain to parents that if constipation has been chronic, treatment is difficult and that child will need prolonged treatment and support. One long-term follow up study of children presenting under the age of 5 years demonstrated that 50% recovered within 1 year and 65-70% recovered within 2 years. That’s a lot of children that didn’t recover. Most people recommend a multifactorial approach to treatment.

1. Discuss diet interventions. Increase fluids, fiber, fruits and vegetables. Decrease amounts of constipating foods like milk products, cooked carrots and bananas.

2. Use pediatric enemas to remove impaction if present.3. Use stool softeners +/- osmotic laxatives to keep stools soft and rectum empty.4. Behavioral management. Have child sit on the toilet for 10 minutes twice a day and

attempt to have a bowel movement. If child soils underwear, may need to encourage child to sit on toilet with greater frequency until they have a large bowel movement. Praise child when successful and avoid punishment. If child has an accident, make sure they cleanup expediently.

5. Once your child is potty trained, never put them back into diapers.6. Schedule regular follow-up appointments.7. Children often need to continue stool softeners for at least 3 months if constipation

has been chronic.

References:

1. Loening-Baucke V., Encopresis and Soiling., Pediatric Clinics of North America, February 1996.2. Loening-Baucke V., Chronic Constipation in Children., Gastroenterology, 1993; 105: 557-563.3. Nolan T, Oberklaid F, New Concepts in the Management of Encopresis., Pediatrics in Review, Vol.

14, November 1993.Return To Table of Contents

CROUP

Important History

1. Nature of onset – sudden or gradual? What was child doing at time of onset? Very sudden onset may suggest foreign body aspiration.

2. Has the child had URI symptoms?3. Immunization history – most cases of epiglottitis caused by H. flu.4. Is there past history of croup or stridor? Some children have recurrent bouts of croup.5. Is there history of intubation?

Differential Diagnosis

Foreign body aspirationSubglottic stenosis – secondary to: congenital hemangioma, human papillomavirus

(warts), traumatic intubation.Bacterial Tracheitis (Staph)LaryngotracheobronchitisLaryngotracheobronchopneumonitisEpiglottitis (Hib)

Croup (laryngotracheitis)

The word croup is often used to identify several different respiratory illnesses/entities with varying degrees of inspiratory stridor, barky cough and hoarseness. Stridor is often accentuated by crying and being excited. Occurs in children between 6 months and 6 years. Most commonly refers to viral laryngotracheitis or recurrent spasmodic croup which are distinct entities.

Viral laryngotracheitis1. common etiologies – parainfluenza, influenza, RSV, adeno, and

rhinovirus.2. Often preceded by URI symptoms, as well as accompanied by fever.

Spasmodic Croup1. Sudden onset, always at night.2. Usually no URI or very mild and no fever.3. Runs in families and tends to be recurrent in same child.4. Usually easily relieved by moist air.

Treatments

1. Majority of cases seen in outpatient setting and are mild. Traditional antecdotal treatments include humidified air either hot or cold. No systemic review nor randomized controlled trial ever done to evaluate these treatments.

2. Steroids (inhaled or systemic) – usually given as a single IM dose of 0.6mg/kg of Dexamethasone in ER or Urgent Care setting for moderate to severe cases. Has been shown to improve symptoms and reduce hospitalizations. Some studies indicate that inhaled Pulmicort just as good as systemic Dexamethasone.

3. Nebulised Racemic Epinephrine – used in moderate to severe cases. Has been shown to reduce symptoms within 30 minutes, but associated with rebound/or return to baseline at 2 hours out in a large number of children. Therefore, if racemic epinephrine given in ER setting, need to watch child for at least 2 hours.

4. Indications for hospitalization include: cyanosis, respiratory distress/WOB, not improving or worsening, anxious family or no guarantee of follow-up.

References:

1. Feigin, Cherry, Texbook of Pediatric Infectious Diseases, Edition 4, Vol. 1.2. Ruddy, RM., Croup – Has Management Changed?, Contemporary Pediatrics, Vol. 10, December 1993.Return To Table of Contents

PEDIATRIC DENTISTRY General Information

Although most infants begin tooth eruption by 6 months of age, there is tremendous variation. Normal number of primary teeth is 20 and there are 32 permanent teeth. Mandibular central incisors are often the first to erupt followed by the maxillary central

and lateral incisors. There may be familial cases of absence of individual teeth and certain conditions may be involved with delayed or absent tooth development. Some are: 1. Down Syndrome 2. Ectodermal dysplasia 3. Hypothyroidism or hypopituitaryism.4. Cleft palate.

Variations at birth

1. Natal teeth – usually are early erupting primary teeth rather than supernumerary teeth. If removed, spacing may be disrupted and lead to orthodontia problems later. If the tooth is loose or is irritating mucous membranes or tongue, and interfering with nursing, tooth should be removed. 2. Epstein's Pearls - on the hard palate and are yellow-whitish deposits of epithelial cells3. Bohn nodules -similar yellow-whitish cysts on the alveolar ridge.4. Short lingual frenulum (tongue tie) - usually doesn't interfere with feeding or speech

and should be left alone. 5. Bifid uvula is often normal but may be associated with submucosal cleft

Teething Although teething may be associated with some discomfort and increased drooling, there is no scientific evidence that it causes systemic symptoms like fever, diarrhea, or rashes. Treatment is symptomatic with acetaminophen and biting on hard, cold objects. Eruption cysts are bluish blood-filled lesions that are on the gums and may precede the eruption of a tooth. May be painful and resolves after the eruption of the tooth. Often difficult to tell when child actually teething. Infants naturally start drooling around 4 months as well as put everything in their mouths as a way of exploring their environment. Both these things are often interpreted by the parents as signs of teething.

Fluoride

With the addition of fluoride to public water supplies, the incidence of dental caries has declined sharply. If there is greater than 0.6 ppm of fluoride in the water, there is no reason to supplement. Please see the attached chart regarding local water supplies and fluoride supplementation (chart not available). Most infant bottled water contains fluoride and it is important that infants getting concentrated or powdered formulas are mixing the powder with fluoridated water. Although not clear-cut, most experts believe that breast fed infants do not need supplemental fluoride. Excessive fluoride intake may lead to fluorosis, which is staining of the enamel. This is not reversible. Many dental products including rinses and toothpaste contain fluoride and it is important to tell parents to limit the exposure of their children to these products.

Nursing Caries Associated with bottle and breastfeeding. Secondary to prolonged exposure to sugars that are acted upon by bacteria (ie. Streptococcus mutans). Occurs when infants fall asleep with bottle or breast in mouth. During this time there is decreased saliva production and tongue action. May also be associated with frequency of sugar exposure. Often not painful. Starts initially on the lingual surface of upper teeth and may go unnoticed until the enamel is destroyed. Important to discourage frequent use of bottle as pacifier and going to bed with a bottle. If treatment not instituted, decay may affect the permanent

teeth. Important to initiate discussions with parents about this problem. Significant number of caries may interfere with nutrition.

Color Changes of Teeth

1. Staining secondary to medicines like iron- reversible 2. Fluorosis 3. Trauma can cause grayish tooth .4. Tetracycline exposure. 5. Greenish-black discoloration at gingival margin secondary to tartar and calculus.6. Enamel and dentin abnormalities may cause brown discoloration

Thumb-sucking and Pacifiers

This is a controversial area with much bias by individual pediatricians and dentists. In general, if the child stops prior to the eruption of the primary teeth there will be few problems. Sucking is a natural soothing mechanism and parents must be reassured that most children do not go to school with a pacifier. Remedies such as covering thumb with bandaid or sour tasting liquid applied to finger have never been proven to work.

Trauma

1. Try to save all permanent teeth that are avulsed. Must see dentist immediately. Should either transport in socket or cold milk.

2. Most primary avulsed teeth aren't saved 3. Encourage use of mouth guards in sports.

Preventive Dentistrv

1. First visit recommended at three years of age and every 6 months afterward.2. Early cleaning with cloth or gauze even before teeth erupt. 3. Most young children need help brushing their teeth until 10 years of age.4. Diet recommendations especially the frequency of sugars, nursing, and bottles.5. Sealants to prevent caries of pits and fissure areas.

References

1. Shusterman, S. DMD, Pediatric Dental Update, Pediatrics in Review, August 1994.2. Nelson’s Textbook of Pediatrics3. American Academy of Pediatrics and NIH Policy Statements on Fluoride use.

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NOCTURNAL ENURESIS

Defined as involuntary voiding at night (bedwetting). Can be further divided into complicated and uncomplicated as well as primary and secondary. Nocturnal enuresis is complicated if accompanied by severe daytime frequency or urgency, daytime incontinence, poor urinary stream, infection, chronic constipation or encopresis, or an

abnormal neurologic exam. Primary enuresis is defined as having never been dry for a period of more than 6 months. Secondary enuresis is defined as the onset of bedwetting after having been dry at night for a period of at least 6 months. Infectious and psychological etiologies are more common in secondary enuresis. The following information will talk specifically about primary, uncomplicated nocturnal enuresis.

The incidence of primary nocturnal enuresis is approximately 15% at 5 years old. Afterwards, about 15% of bedwetters will improve with each year that passes. Approximately 1-2% of adults are still bedwetting (interestingly, this statistic came from the number of WWII military recruits that were rejected for bedwetting). Boys are more commonly affected than girls.

Important History

1. Establish whether primary or secondary.2. Family history – 40% incidence if one parent affected, 70% if both parents were

enuretic.3. History of constipation or encopresis.4. Symptoms of UTI.5. Symptoms of diabetes.6. Symptoms of sleep apnea.7. Emotional or behavioral difficulties.8. Neurologic symptoms – weakness, bowel control changes, gait changes.9. Voiding history – daytime incontinence, daytime frequency or urgency, amount of

urine when goes, stream, difficulty starting or stopping.10. Fluid intake history – amount, time and type.

Physical Exam

1. Examination of underwear for urine or stool.2. Examination of genitalia.3. Neurologic exam – plantar flexion, big toe flexion and extension, sensation on side of

foot, heel and perineum.4. Abdominal exam for masses.5. Inspection of back and spinal column.

Laboratory Examination

1. Urine analysis and culture.2. Measurement of functional bladder capacity (hold urine as long as possible, void, and

measure volume).

Etiology/Cause

Often multifactorial.

1. Genetic.2. Reduction in functional bladder capacity (not anatomic).3. Bladder instability or Dysfunctional voiding – more often cause in diurnal enuretics.4. Relative nocturnal polyuria and abnormal ADH secretion – never definitively proven,

probably a cause in some.5. Infection (bacterial or pinworms).6. Obstructive sleep apnea.7. Sleep disorders – controversial and never proven.8. Delay in neurologic maturation.9. Stress and psychologic causes – never proven.10. Diet (ie. Caffeine) – never proven.

Treatment

Most people would agree that no need to aggressively treat until child at least 7-8 years old and motivated to change.

1. Change daily fluid intake so that drinking more during morning and afternoon and less during evening. Significantly decrease intake of caffeinated products.

2. Bladder retention training during daytime.3. Behavioral modification – Keep a calendar of dry and wet nights and reward and

praise for successive dry nights. Make child active participant in process by having them change their clothes and sheets and bring to laundry.

4. Alarms – (cost about $60) good long term success if used properly and child and family motivated. Should be continued until child dry 4 consecutive weeks.

5. Imipramine and DDAVP – often good short-term success, but high relapse rates when stop medication. Useful for special occasions like sleepovers and vacations. Both usually used in 3 month trials and weaned off.

6. Should discourage waking child at night because has not been shown to resolve bedwetting and is disruptive. In addition, should discourage prolonged use of diapers and pull-ups – encourages regressive behavior and doesn’t allow child to sense wetness. Should never punish child – remember bedwetting is involuntary.

References:

1. Jalkut MW, Lerman SE, Churchill BM., Enuresis., Pediatric Clinics of North America, Vol. 48, #6, December 2001.

2. Tietjen, Douglas, Husmann., Nocturnal Enuresis: A Guide to Evaluation and Treatment., Mayo Clinic Proceedings, 71: 857-62, 1996.

3. BMJ Publishing Group, Clinical Evidence Pediatrics, Issue 7, 2002.Return To Table of Contents

SLEEP PROBLEMS

Night Terrors

1. Night terrors are a common arousal disorder that affects about 3% of the population. It has a greater incidence in boys and there is often a positive family history.

2. Occurs most commonly between the ages of 18mo-6 years. 3. Occurs during stage 3 and 4 of sleep (non-REM) - thus the incidence is greatest

during the first 2hours of sleep. Tends to occur in bouts of up to 20x/night and lasts for several weeks.

4. Child is very agitated and will be sweating, tachycardic, tachypneic, and has dilated pupils.

5. Child doesn't awake and is unable to be comforted, won't respond to the parents, and doesn't remember the incident in the morning.

6. Very frightening to the parents.7. Increased incidence during times of stress. Triggered by excessive fatigue, change in

routine or daily stress. 8. Parents should be instructed to protect child from hurting himself secondary to

thrashing about. Also, there is an 18% incidence of sleep walking. If this occurs, some mechanism must be used to awake the parents if the child tries to leave their room.

9. Treatment a. Don't wake the child b. Protect the child from injury c. Reassure the parents that night terrors will spontaneously disappear. d. Relieve any stressors if possible.

Nightmares

1. 10-50% incidence, girls >boys, most common between 3 and 6 years. 2. Nightmares are frightening dreams that occur in the second half of the sleep cycle

during REM. 3. The child awakens from sleep and has distinct memory of the dream. 4. Able to be comforted by the parent 5. Increased incidence during stresses such as familial difficulties and toilet training.6. Treatment

a. reassure the child (preferably in bed). b. don't get into long discussions about the dream. If the child wants to discuss the content, do it during the daytime. Also, don't reinforce fear (ie. looking for monsters with flashlight). c. Relieve any stressors if possible.

References

1. Blum, Nathan and Carey, William. Sleep Problems Among Infants and Young Children. Pediatrics in Review, March 1996.

2. Sleep Disorders. Pediatrics in Review 2001, 22; 327-342.Return To Table of Contents

PHARYNGITIS/STREP THROAT Like many other infectious diseases, most cases of pharyngitis are viral in origin and require no treatment. That said, it is important to recognize strep throat and treat it appropriately to avoid its complications.

Clinical Features of Group A Beta Hemolytic Strep

1. >2 years old and < 18 years old.2. Sore throat3. Fever4. Abdominal pain/vomiting 5. Absence of runny nose, conjunctivitis, diarrhea, and cough 6. More frequent in late winter and spring, uncommon in summer, but can occur all year

long.

Physical Findings in Streptococcal Pharyngitis 1. Red pharynx with exudate on tonsils and petechiae on palate.2. Sand-papery rash greatest on trunk, may be pruritic (although Strep-associated rash

can appear like anything including hives).3. Bilateral tender cervical adenopathy

Diagnosis of Strep Pharyngitis 1. Throat culture on sheep blood agar and incubate for 24-48 hours. The throat culture is

90- 95% sensitive. Technique is important and must get the posterior pharynx. The number of colonies on sheep blood agar is not important. A bacitracin disc will differentiate GABS from non-Group A. Also may use a rapid strep test which is less sensitive(80-90%) and as specific(95%) as the throat culture. If rapid test is negative, you must do a throat culture. Not necessary to plate a culture if the rapid test is positive.

2. It is not necessary to culture contacts unless they are symptomatic.3. All suspected streptococcal pharyngitis patients must be cultured or have a “+” rapid

strep test prior to starting antibiotics.4. It is imperative to only culture appropriate subjects to avoid picking up the 10-15% of

the population that are "carriers" of strep. These are patients that have GABHS in throat without a serologic response. The patient is clinically well. These patients are not contagious and are not at increase risk for Acute Rheumatic Fever.

5. Re-culturing after course of treatment is not recommended.

Treatment

1. Oral penicillin/amoxicillin or LA Bicillin IM.2. If penicillin allergy, than erythromycin.3. No known resistance of GABHS to penicillin reported. Treatment failures thought to

be related to non-compliance, ping-pong spread, or co-infection of pharynx by Beta-lactamase producers.

4. Patients are no longer contagious 24 hours after starting therapy.

Complications of Strep Pharyngitis

1. Acute rheumatic fever and acute glomerulonephritis (not prevented by therapy).2. Peritonsillar abscess.

References

1. Pichichero ME et al., Annals Emerg Med, 1995; 25:390-402.Return To Table of Contents

THE PINK OR RED EYE

Differential Diagnosis

ConjunctivitisAllergiesChemical irritationCorneal abrasion/Foreign bodyCongenital nasolacrimal duct obstructionKawasaki syndromeSubconjunctival hemorrhageHordeolum (Stye)

Important History/PE Findings

1. Time of year and history of atopy – allergic conjunctivitis.2. Acute onset or feeling of something in eye – corneal abrasion/foreign body.3. Presence of ear pain/otitis media – nontypeable H. flu.4. Presence of sore throat or tonsillar exudate – adenovirus.5. Maternal history of perinatal infection – chlamydia/GC.6. Presence of bloody discharge – GC or chemical irritation.7. Presence of preauricular lymph nodes – viral.8. Presence of vescicular lesions around eye – herpes.9. Unilateral or bilateral involvement.10. Acute or chronic.

Conjunctivitis

1. Majority of nonsevere bacterial conjunctivitis caused by non-typable H. influenza, S. pneumonia and Moraxella species.

2. In general, gram stain and culture of discharge not necessary unless suspecting N. gonorrhea.

3. Viral conjunctivitis tends to have a more watery discharge instead of purulent and associated with a prodromal URI.

4. Treatment with topical antibiotics for bacterial conjunctivitis shortens the course of the illness to 3-5 days. After 7-10 days no difference in treated vs. untreated cases.

5. Always look in ears. If otitis/conjunctivitis, need to use beta-lactamase resistant antibiotic.

6. Failure of resolution or worsening needs ophthalmologic eval.

7. No scientific evidence that children with conjunctivitis need to be out of school, but most schools require note to return.

8. Good handwashing and separate towels/linens to prevent spread in household.

Congenital Dacryostenosis (Nasolacrimal duct stenosis)

1. Most obstructions occur where nasolacrimal duct enters nasal cavity. 30% of cases bilateral.

2. Presents as infant with a wet/tearing eye, occasionally with crust or mucous in medial corner.

3. Usually resolves by 12 months of age. If not, may need probing under anesthesia.4. Occasionally accompanied by conjunctivitis – will be red with increased purulent

discharge.5. Need to rule out congenital glaucoma. Usually infant will be photophobic and

irritable.

References

1. Gigliotti, F., Management of the child with conjunctivitis, Pediatric Infectious Disease Journal, Vol. 13, No.12, pp1161-1162, December 1994.

2. Prasad, S., Congenital nasolacrimal duct obstruction, Pediatrics in Review, March 1994.3. Wagner, R., The differential diagnosis of the red eye, Contemporary Pediatrics, pp.26-48, July 1991. Return To Table of Contents

TOlLET TRAINING

Most children complete toilet training between 18 and 30 months of age, although there is cultural variation. There are some variations between children in whether bladder or bowel control is established first. Nighttime control of bladder function usuallv comes later and mav be delaved for vears in some individuals.

The most important tip for toilet training is not to initiate training until the child is ready and to cease with the process if the child is not interested or unsuccessful. Toilet training should be child-oriented. If parents are unsuccessful, they may try again in a couple of months.

Indications of Readiness for Toilet Training

1. The child has developed the intelligence level and vocabulary to understand toilet training. They must comprehend words such as pee-pee, poop, wet, dry , and potty. A parent should be consistent in what words they use to describe these habits.

2. They must understand what the purpose of the potty is. A child develops this understanding by watching parents and sibs using the bathroom and trying to imitate their actions.

3. The child appears to dislike being wet and dirty. They want to be changed.4. They are aware that they have to go. This will be illustrated by pulling on their

genitals, hopping around, squatting, and telling the parents that they have to go . 5. The child demonstrates sphincter control by being dry and clean more often.

Steps to Initiate Toilet Training

1. Begin the process during emotionally relaxed times. For example, the birth of a new sib would not be an ideal time.

2. Buy the child their own potty chair that enables the child to have their feet on the ground. Involving the child in the purchase and being excited about the purchase is helpful.

3. Try to place the child on the potty chair when the chance of success will be high. Behaviors like touching genital areas or squatting may be cues. Also, after meals or following naps are also good times to sit on the potty.

4. Positive reinforcement. This can start with praising the child for just sitting on the potty chair. May also give the child a small reward if they are successful like snacks or stars on a calendar.

5. Be patient if the child is unsuccessful or has an accident. Change the child soon after they go to avoid mixed messages.

6. "Big boy or girl" pants are often helpful in encouraging the child. Use diapers for naps and sleeping time only.

7. Encourage both parents as well as the babysitter to be on the same wave-length throughout the process.

It is important to reiterate to parents that toilet training is not a competitive event and some children are trained at different rates than their sibs or friends' children. Most children will be trained by 3 years of age and often by themselves. Pressure, punishment, and negative feedback will often prolong the process and cause complications and stress for the child.

References

1. Stadtler, Gorski and Brazelton. Toilet Training Methods, Clinical Interventions and Recommendations. Pediatrics, Vol. 103, No. 6 Suppliment June 1999, pp. 1359-1361.

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