AUGUST 25 -27, 2017 UPDATE Loews Chicago O'Hare Hotel ... · Bryon J. Lauer, and Nancy D. Spector Pediatrics in Review 2011;32:341-349 Increased production ABO incompatibility Red

•••••• • acofp••••••• INTENSIVE

UPDATE & BOARD REVIEW

AUGUST 25 - 27, 2017 Loews Chicago O'Hare Hotel

Rosemont, IL

INNOVATIVE • COMPREHENSIVE • HANDS-ON

acofp Am eric an College of

Osteopathi c

Family Physicians

The American College of Osteopathic Family Physicians is accredited by the

American Osteopathic Association Council to sponsor continuing medical

education for osteopathic physicians.

The American College of Osteopathic Family Physicians designates the lectures

and workshops for Category 1-A credits on an hour-for-hour basis, pending

approval by the AOA CCME, ACOFP is not responsible for the content.

Baby Basics

Sarah Hall, DO

8/7/2017

1

Sarah Hall, D.O.

August 25, 2017

ACOFP Intensive Board Review

Jaundice of the newborn

Ill appearing newborn

Failure to thrive

Respiratory Distress

Vaccination Schedule

Overview

Presentation

Differential Diagnosis

Risk factors

Work up

Treatment

Medication

8/7/2017

2

You are seeing a newborn at 72 hours for an initial newborn visit in your office. The baby was born at 37 weeks after a prolonged spontaneous vaginal delivery and is exclusivelybreastfeeding. APGARS were 7/9. Discharge papers indicate that at 24 hours, the baby’s Total bilirubin level was 8 mg/dL and the direct bilirubin level was 0.2 mg/dL. The baby is urinating and sleeping well. Baby is nursing every 3-4 hours for 10 minutes but falls asleep at the breast. +3 stools in the last 24 hours. On exam, the infant is afebrile and has lost 13 percent of birth weight. The baby’s eyes, tongue, and skin appear yellow down to the umbilicus. Anterior fontanelle is open and flat. The infant is alert and has a 3 cm cephalhematoma located on the left parietal area. A STAT Total serum bilirubin level is 17 mg/dL at 72 hours.

A. Reassure parents that this is normal. And follow up in 2 days.

B. Repeat total and direct bilirubin levels in 24 hours.

C. Admit the infant and initiate exchange transfusion.

D. Initiate home phototherapy and follow up in 24 hours.

E. Admit the infant and start IVIG and phenobarbital.

Overview

Presentation


Risk factors

Work up

Treatment

Medication

8/7/2017

3

Defined as total serum bilirubin > 95th % on the Bhutani nomogram

Almost all newborns will have values over 1 mg/dL

Yellowish discoloration of skin and conjunctiva caused by bilirubin deposition

Normal neonatal changes lead to increased bilirubin, decreased bilirubin clearance, and increased enterohepatic circulation

Unconjugated hyperbilirubinemia

Peak values occur at 48-96 hours

Resolves within 1-2 weeks after birth

Pathologic if noted in the first 24 hours of life

Different nomograms for determination of risk, phototherapy treatment and exchange transfusion

8/7/2017

4

Bryon J. Lauer, and Nancy D. Spector

Pediatrics in Review 2011;32:341-349



8/7/2017

5



Increased production

ABO incompatibility

Red blood cell membrane defects

Erythrocyte enzymatic defects

Polycythemia (delayed cord clamping)

Sepsis

Criggler-Najjar syndrome

Gilbert Syndrome

Maternal Diabetes

Congenital hypothyroidism

Galactosemia

Decreased clearance

Increased enterohepatic circulation Intestinal obstruction

Breastmilk jaundice

Breastfeeding failure

8/7/2017

6

Severe neonatal bilirubinemia TB> 25 mg/ dLBilirubin induced neurologic dysfunction (BIND) Acute bilirubin encephalopathy (ABE)

Chronic and permanent sequela of BIND=kernicterus

***Treated with exchange transfusion

Transcutaneous bilirubin level

Serum total and direct bilirubin

CBC

Blood type

Continuation of breastfeeding, increase frequency, formula supplementation

Phototherapy

Exchange transfusion

8/7/2017

7

Phototherapy

24 hrs-bilirubin > 12 mg/dL

48 hrs-bilirubin>15 mg/dL


24 hrs-bilirubin >19 mg/dL


72 hrs- bilirubin>24 mg/ dL


Phototherapy




24 hrs-bilirubin >16.5 mg/dL


72 hrs- bilirubin> 21 mg/ dL


IV Immune globulin (IVIG) if isoimmune hemolytic disease

Ursodeoxycholic acid Cholestatic jaundice

No longer routinely used Phenobarbital

Metalloporphyrins

8/7/2017

8

You are seeing a newborn at 72 hours for an initial newborn visit in your office. The baby was born at 37 weeks after a prolonged spontaneous vaginal delivery and is exclusively breastfeeding. APGARS were 7/9. Discharge papers indicate that at 24 hours, the baby’s Total bilirubin level was 8 mg/dL and the direct bilirubin level was 0.2 mg/dL. The baby is urinating and sleeping well. Baby is nursing every 3-4 hours for 10 minutes but falls asleep at the breast. +3 stools in the last 24 hours. On exam, the infant is afebrile and has lost 13 percent of birth weight. The baby’s eyes, tongue, and skin appear yellow down to the umbilicus. Anterior fontanelle is open and flat. The infant is alert and has a 3 cm cephalhematoma located on the left parietal area. A STAT Total serum bilirubin level is 17 mg/dL at 72 hours.

A. Reassure parents that this is normal. And follow up in 2 days.





A. Reassure parents that this is normal. And follow up in 24 hours.





8/7/2017

9

A 2 week old infant presents to the office with mom and complaint of poor feeding for the last 2 days. She has noted that the infant has been more fussy and has been sleeping more. The baby has been formula feeding 2 ounces/ 3-4 hours until 2 days ago at which time the infant would only take 1 ounce every 6-8 hours. Urine output has decreased from 8 wet diapers to 3 wet diapers/ day. Vitals-T101 ° F, HR-167, RR-60-fontanelle is sunken and MM dry. Heart is tachycardic without Murmurs. Lungs are clear without wheezes or rhonchi. Abdomen is soft, no masses or erythema noted at umbilicus. Decreased bowel sounds in all quadrants.

A. Administer acetaminophen and obtain labs.

B. Administer ceftriaxone and follow up in 24 hours.

C. Admit the infant for work up and empiric antibiotics.

D. Arrange for home health to assist with improved feeding.

E. Obtain prenatal history and birth history.

Overview

Presentation


Risk factors

Work up

Treatment

Medication

8/7/2017

10

Fever is the prominent symptom of many different conditions

May be the only symptom on presentation

Fever is a rectal temperature over 100. 4°F or 38 ° C

Type of Infection Prevalence

Urinary tract infection 72

Bacteremia 20

Soft tissue infection/ cellulitis 13

Meningitis 6

Pneumonia 4

Temperature over 100. 4°F or 38 ° C

Lethargy

Poor tone

Poor feeding

Respiratory distress

8/7/2017

11

Infections Bacterial sepsis

UTI

Bacteremia

Pneumonia

Cellulitis

Meningitis

Omphalitis

Osteomyelitis

Pyelonephritis

Pertussis

Viral infection HSV

Enterovirus

Influenza

Varicella

Adenovirus

RSV

Bronchiolitis

Myocarditis

Trauma Inflicted Head injury Unintentional injury

Neurological Seizures

Surgical/ GI Pyloric stenosis Malrotation with

volvulus Incarcerated hernia NEC

Cardiac Congenital heart

Disease SVT

Endocrine Congenital Adrenal

hyperplasia

Metabolic Hypoglycemia Inborn errors of

metabolism

Hematologic Acute bilirubin encephalopathy

Toxic exposure Methemoglobinemia

Carbon monoxide poisoning

Medication overdose

Apparent life threatening event (ALTE)

Kawasaki Disease

8/7/2017

12

Age younger than 28 days

Maternal infection in pregnancy or labor

Temperature over 40° C (104 F)

Unimmunized

Prematurity

Chronic illness

Antibiotic administration with in 7 days

Social barriers to follow up

History and Physical

CBC and CMP

Blood culture

Urine culture

CSF culture

Total and direct bilirubin if jaundiced

HSV culture of vesicles if present

CXR

Abdominal xray and ultrasound

CT head and skeletal survey if trauma or abuse

EKG if CHD suspected

8/7/2017

13

Age Organism Empiric treatment

Neonate (<28 days) GBSE.ColiListeriaEnterococcusS. AureusHSV

Ampicillin + Cefotaxime OrAmpicillin + Aminoglycoside and Acyclovir

Infant (29-90 days) S. PneumoniaH. InfluenzaN. MeningiditisGBSE.ColiListeriaEnterococcusS. AureusPseudomona

Well appearing, no CSFpleocytosisCeftriaxone or cefotaxime

CSF pleocytosis or ill appearingVancomycin + Ampicillin and Ceftriaxone or cefotaxime

A 2 week old infant presents to the office with mom and complaint of poor feeding for the last 2 days. She has noted that the infant has been more fussy and has been sleeping more. The baby has been formula feeding 2 ounces/ 3-4 hours until 2 days ago at which time the infant would only take 1 ounce every 6-8 hours. Urine output has decreased from 8 wet diapers to 3 wet diapers/ day. Vitals-T101 ° F, HR-167, RR-60-fontanelle is sunken and MM dry. Heart is tachycardic without Murmurs. Lungs are clear without wheezes or rhonchi. Abdomen is soft, no masses or erythema noted at umbilicus. Decreased bowel sounds in all quadrants.






8/7/2017

14






An 18 month old male presents to your office for well child check. His weight has dropped from 30th

percentile to 5th percentile since his last well check 6 months ago. Father reports that he is a picky eater and mainly consumes apple juice and rice cereal. He has refused milk and his mother believes he is lactose intolerant and therefore has not been receiving any. He has 6 wet diapers/ day and 4-5 loose stools/ day. On physical exam you note symmetric bruising on the upper arms and healed circular burns on the buttocks and lower back.

A. Contact a pediatric dietician for outpatient consultation

B. Inpatient admission for work up and initiation of nutritional support

C. Notify local authorities to escort the father out of the clinic

D. Perform labs to screen for underlying medical disorder

E. Perform skeletal survey for inherited bone disease

8/7/2017

15

Overview

Presentation


Risk factors

Work up

Treatment

Medication

FTT is a sign not a diagnosis

Occurs in 5-10 % of children in primary care

Also called weight faltering, or failure to gain weight appropriately Weight loss across two standard deviations on the

growth chart

Weight less than 80 percent ideal weight for age

Weight below the 2nd percentile

Rate of daily weight gain less than expected

8/7/2017

16

Thorough History and Physical with basic labs Birth history

Prenatal history

Past Medical History

Family History

Review of Systems

Diet and feeding Food preferences, length of feeding

HIV

Primary immunodeficiency

Intestinal malabsorption

Congenital heart disease

Kidney disease

Liver disease

Chronic lung disease

Malignancy

Prematurity

Developmental delay

Congenital anomalies

Intrauterine exposures

Lead poisoning

Anemia

Inadequate intake **

Increased metabolic rate

Maldigestion

Malabsorption

8/7/2017

17

Poverty

Health and nutrition beliefs

Social isolation

Life stressors

Poor parenting

Disordered feeding techniques

Substance abuse, mental health disorder

Violence or abuse

History Possible Diagnosis

Diarrhea Malabsorption

Chronic constipation Decreased appetite

Recent travel Infectious diarrhea

Chronic OM Immune deficiency/ structural defect

Snoring Adenoidal hypertrophy

Wheezing Mechanical obstruction or ILD

Vomiting GERD or obstruction

Gagging or prolonged time Oral motor dysfunction

Polyuria, polydipsia, polyphagia Diabetes

Frequent infections Immune deficiency

Examination Potential Diagnosis

Vital signs Adrenal, thyroid, renal, increased metabolic demands

General appearance Anemia, malnutrition, genetic syndrome

Head and neck: Microcephaly Neurologic disorder, Fetal alcohol syndrome

Delayed closure of fontanelle Vit D deficiency, low thyroid

Thyroid enlargement Thyroid disease

Chest: wheezing Cystic fibrosis, asthma

Cardiac murmur Congenital or acquired heart disease

Abdomen: Distention, increased BS Malabsorption

Hepatosplenomegaly Liver disease, glycogen storage disease, malignancy

8/7/2017

18

Examination Potential Diagnosis

Genitourinary: Abnormalities Endocrinopathy

Rectal fistulae Crohn disease

Musculoskeletal: Clubbing Cardiac or pulmonary disease with low O2

Bony deformities Rickets

Edema Protein deficiency

Neurologic: Abnormal DTR’s Cerebral palsy

Hypotonia, weakness, spasticity Cerebral palsy

Skin and Mucus Membranes: Scaling Zinc deficiency

Bruises, rashes Possible abuse or neglect

Lab evaluation

CBC

UA

CMP

Lead testing

Phosphorus

Albumin level

Upper GI

SBFT

Swallow study

Gastric emptying scan

Diagnostic imaging

Nutritional

Medical

Developmental/behavioral

Psychosocial factors

Interdisciplinary approach is critical to success

8/7/2017

19

Indication for Hospitalization Severe malnutrition

Dehydration

Serious illness

Child at risk for harm

Failed OP management

Severe parental mental health disorders

Loss of follow up due to location or transportation

Finding Mild Moderate Severe

Pulse Normal Rapid Rapid, weak, orabsent

Systolic pressure Normal Normal to low Low

Respirations Normal Deep, may be ↑ Deep, ↑ or ↓

Buccal mucosa Normal Sunken Markedly sunken

Anterior fontanelle

Normal Sunken Markedly sunken

Eyes Normal Sunken Markedly sunken

Skin turgor Normal Reduced Tenting

Skin Normal Cool Cool, mottled, acrocyanosis

Urine output Normal Markedly reduced

Anuria

Systemic signs Increased thirst Listlessness, irritability

Grunting, lethargy, coma

Outpatient management generally successful

Dietary advice by PCP or pediatric dietician

Changes to feeding environment

Home based support (visiting nurse)

Referral to community, state or federal assistance programs

Regular follow up to monitor weight

8/7/2017

20

Frequent small volume feedings

Calorie dense formulas progressed slowly

Monitor for refeeding syndrome or “nutritional recovery syndrome”

Involve an interdisciplinary team

Daily multivitamin with iron and zinc

Cyprohepatidine 0.12 mg/ kg twice daily

Appetite stimulant used only in children that have not had catch up weight in 3-6 months of fortification of food of formula/ breast milk

Supplementation of oral feedings with nasogastric feedings during the daytime or nighttime

8/7/2017

21

An 18 month old male presents to your office for well child check. His weight has dropped from 30th

percentile to 5th percentile since his last well check 6 months ago. Father reports that he is a picky eater and mainly consumes apple juice and rice cereal. He has refused milk and his mother believes he is lactose intolerant and therefore has not been receiving any. He has 6 wet diapers/ day and 4-5 loose stools/ day. On physical exam you note symmetric bruising on the upper arms and healed circular burns on the buttocks and lower back.











8/7/2017

22

A 3 year old female presents with her mother with a complaint of productive cough over the last 3 days. The sputum is described as copious and is yellowish white in color. She does go to day care and there have been several kids out due to some respiratory illness. Vitals T 102°F, HR 150, RR 65. She is ill appearing and clinging to her mother. Heart is tachycardic without murmur. Lungs reveal rhonchi in the right lower lung field. Retractions are noted.

A. Group B streptococcus

B. Klebsiella pneumonia

C. Listeria monocytogenes

D. Pseudomonas aeruginosa

E. Streptococcus pneumonia

Overview

Presentation


Risk factors

Work up

Treatment

Medication

8/7/2017

23

10 % of pediatric emergencies

20 % of hospitalization

Respiratory arrest is the most common cause of cardiac arrest in pediatric patients

Tachypnea *

Retractions-sternal and intercostal *

Nasal flaring

May be agitated, restless or combative

May have wheezing or stridor

May have accessory muscle use

Sniffing or tripod position may be assumed

Cyanosis may be present

Age Respiratory rate

0-3 month 43

3-6 month 41

6-9 month 39

9-12 month 37

12-18 month 35

18-24 month 31

2-3 year 28

3-4 year 25

4-6 year 23

6-8 year 21

8-12 year 19

12-15 year 18

8/7/2017

24

Respiratory

Infection

Asthma

Anaphylaxis, inhalation, chemical exposure

Foreign body

Airway anomalies

Chest wall trauma or abnormalities

Pulmonary conditions or trauma

Congenital heart disease

Acute decompensated heart failure

Myocarditis

Pericarditis

Arrhythmia

Shock

Cardiac tamponade

Myocardial infarction

Cardiovascular

Nervous system

Depressed ventilation Ingestion

CNS trauma

Seizures

CNS infections

Hypotonia

Pulmonary aspiration

Hypoventilation due to abdominal pain or distention

Gastroesophageal reflux with pulmonary aspiration

Gastrointestinal

Metabolic or Endocrine

Metabolic acidosis

Hyperthyroidism

Hypothyroidism

Hyperammonemia

Hypocalcemia

Acute severe anemia

Methemoglobinemia

Carbon monoxide poisoning

Acute chest syndrome

Hematologic

8/7/2017

25

Chronic health problems

Family history of asthma or cardiac disease

Immune compromise

Prematurity

Tobacco exposure

Poor nutrition

Lack of vaccinations

HISTORY

Trauma

Change in voice

Onset and duration of symptoms

Associated symptoms

Exposures

Previous episodes

Underlying medical problems

Mental status

Position

Cyanosis

drooling, dysphagia

Vitals

Pulmonary Tracheal deviation

Accessory muscle use

Auscultation

Palpation/ Percussion

CNS

Cardiac Gallop, murmur, rales

JVD, hepatomegaly

GI

Metabolic Kussmaul breathing

Endocrine

Allergy

8/7/2017

26

Upper Airway

Sniffing position

Nasal flaring

Prolonged inspiration

Retractions

Abnormal Voice

Stridor

Barking cough

Transmitted upper airway sounds

Retractions

Nasal flaring

Prolonged expiration

Wheezing

Grunting

Rales

Pleural rub

Bronchophony

Pulsus paradoxus

Lower Airway

Pulse oximetry

ABG

Chest Xray

CBC

CMP

Blood cultures, UA, CSF If infection with CNS

signs

EKG

Echocardiography and ultrasound

Lateral neck X-ray

Abdominal X-ray

CT head and chest

Airway management (PALS or NRP)

Needle decompression if indicated

Disease specific management: Croup: racemic epinephrine and decadron

Tracheitis: intubation and antibiotic until cultures return

Retropharyngeal abscess: ENT consultation with antibiotics and steroids

8/7/2017

27

Age Organism Treatment

<1mo Group B strep, E. Coli, Klebsiella, Pseudomonas, Listeria

Amp + Aminoglycoside OR Amp + Cefotaxime

1-3 moH. influ, S. pneumonia, Grp A or B strep, pertussis

Amp + Cefotax

3mo- 5 yrS. pneumonia, H. influ, Staph aureus, Grp A Strep, pertussis

Cephalosporin + anti-staph or pertussis if indicated

>5yo S. pneumonia, H. influ, Grp A Strep

PCN OR Amp OR Cephalosporin + anti-staph or pertussis if indicated

Bronchodilators may be helpful

Supplemental oxygen

IV hydration

Nebulized hypertonic saline

Antibiotics are not indicated

Chest physiotherapy and OMT

8/7/2017

28

Oxygen

IV hydration

Nebulized albuterol

Steroids-IV or oral

IV Magnesium

A 3 year old female presents with her mother with a complaint of productive cough over the last 3 days. The sputum is described as copious and is yellowishwhite in color. She does go to day care and there have been several kids out due to some respiratory illness. Vitals T 102°F, HR 150, RR 65. She is ill appearing and clinging to her mother. Heart is tachycardic without murmur. Lungs reveal rhonchi in the right lower lung field. Retractions are noted.






8/7/2017

29






Questions:

Sarah Hall, D.O.

OSU Center for Health Sciences

Associate Professor of Family Medicine

[email protected]

8/7/2017

30

Gastroesophageal Reflux

Pyloric stenosis

Constipation

Overview

Presentation


Risk factors

Work up

Treatment

Medication

Physiologic

Passage of gastric contents into the esophagus

Brief therefore no symptoms

Often resolves by 1 year of life

GERD-symptoms with esophagitis, poor weight gain, and respiratory symptoms

8/7/2017

31

Frequent regurgitation

Present in 67 % of infants by 3-4 months

May be associated with periods of prolonged crying

Infant may draw the legs up with or soon after feeding

Sleep disturbances noted

Often not associated with weight loss

GI obstruction or disease

Bilious vomiting

GI bleed

Forceful vomiting

Onset of vomiting after 6 months

Constipation

Diarrhea

Abdominal tenderness

Recurrent pneumonia

Hepatosplenomegaly

Bulging fontanelle

Macrocephaly or microcephaly

Seizures

Hypotonia

Chronic infection

Systemic or Neurologic disease

Nonspecific symptoms Fever

Pneumonia

Lethargy

FTT

8/7/2017

32

Pyloric stenosis

Volvulus

Intussusception

Hirschsprung disease

Gastroenteritis

PUD

Gastroparesis

Pancreatitis

Mass lesion

Subdural hematoma

Intracranial hemorrhage

Hydrocephalus

Sepsis (UTI, pneumonia, meningitis)

Endocrinopathies

Renal insufiency

Prematurity

Neurodevelopmental disabilities

Supine position

Food allergies

Delayed gastric emptying

Medications that relax the LES

Thorough H and P

Esophageal manometry

Esophagogastroduodenoscopy (EGD)

Upper gastrointestinal imaging series

Gastric scintiscan study

Esophagography

Intraesophageal pH probe monitoring

Intraluminal esophageal electrical impedance

Sleep study

8/7/2017

33

Conservative therapy Lifestyle changes

Upright position after feedings

Small frequent feedings

Thickening formula or breastmilk

Proton pump inhibitors

Omeprazole (Prilosec)

Lansoprazole (Prevacid)

Rabeprazole (Aciphex)

Esomeprazole (Nexium)

Hydrogen 2 blockers Ranitidine (Zantac)

Nizatidine (Axid)

Failure of medication therapy for over 12 weeks

Continued respiratory symptoms (Obstructive apnea with confirmed pH monitoring)

Patients with complications of gastroesophageal reflux

Neurologic impairment that requires feeding gastrostomy

8/7/2017

34

The parents of a 2 month old present with concerns that their daughter vomits at least 2 ounces of formula with every feed. There is no blood in the vomit and the baby appears to be hungry after she vomits. She has no respiratory symptoms. They burp her for 5-10 minutes after each feeding. She is at the 70th percentile for height, 50th percentile for weight, and 60th percentile for head circumference which is consistent with her growth measurements since birth. Physical exam reveals a cheerful infant otherwise unremarkable.

A. Order lab tests to rule out underlying medical condition

B. Counsel the parents regarding lifestyle modifications.

C. Refer the baby to a gastroenterologist

D. Prescribe ranitidine

E. Prescribe omeprazole

A. Order lab tests to rule out underlying medical condition

B. Counsel the parents regarding lifestyle modifications.

C. Refer the baby to a gastroenterologist

D. Prescribe ranitidine

E. Prescribe omeprazole

8/7/2017

35

Overview

Presentation


Risk factors

Work up

Treatment

Medication

Hypertrophy of the pylorus leading to gastric outlet obstruction

Occurs in 2-3.5/ 1000 live births

Occurs more commonly in male infants (4:1) and is associated with prematurity

Symptoms begin ~3-6 weeks of age

Infant age 3-6 weeks

Immediate post prandial “projectile” non bilious vomiting

Hungry vomiter

Palpable “olive” in the RUQ lateral to the rectus abdominus (present in 50-90%)

Dehydration may be present

Hypochloremic alkalosis may be present

8/7/2017

36

Gastroesophageal reflux

Gastroenteritis

Eosinophilic gastritis

Cow’s milk protein intolerance or feeding intolerance

Adrenal crisis

Intestinal obstruction

UTI

Toxic ingestion

Hepatobiliary disease

Male gender

Birth order

Maternal smoking

Premature birth

Bottle-feeding

Erythromycin and Azithromycin use

CBC

Venous pH

CMP Electrolytes

BUN/ Creatinine

Liver function

Bilirubin level

8/7/2017

37

Abdominal ultrasonography Operator dependent

Sensitivity and specificity over 95%

Pyloric muscle thickness >4 mm

Pyloric muscle length >19 mm

Pyloric diameter > 14 mm

If Abdominal US non diagnostic Upper GI (UGI)

If UGI non diagnostic Upper endoscopy with

biopsy

Conservative management

Continuous nasal duodenal feedings for several months to allow obstruction to resolve

Balloon Dilation Can be used when general anesthesia is contraindicated

Surgical approach to pylorus is not possible

Pyloromyotomy (preferred treatment) Dehydration and electrolyte abnormalities should be

corrected prior to surgery

• Oral or IV atropine- Relaxes the pyloric musculature

- Not typically preferred

- Small non randomized studies have shown this medication to be effective in ~75 % of infants

8/7/2017

38

Overview

Presentation


Risk factors

Work up

Treatment

Medication

Common problem in pediatric population

30 % of children affected

17-40 % of case begin in the first year of life

Painful, incomplete, or infrequent defection associated with fecal incontinence and abdominal pain

In the absence of organic pathology, 2 of the following must occurFor a child with a developmental age <4 years

1. 2 defecations per week2. At least 1 episode of incontinence per week after the acquisition of toileting skills3. History of excessive stool retention4. History of painful or hard bowel movements5. Presence of a large fecal mass in the rectum6. History of large-diameter stools that may obstruct the toilet

8/7/2017

39

Absence of stool in a bottle-fed infant over 3 days

Absence of stool in breastfed infant over 7 days

Small caliber hard stools

Crying with defecation

Straining with defecation

Irritability

Decreased appetite

Early satiety

Abdominal pain and fullness

Introduction of solid foods

Milk protein allergy or increased intake of dairy

Withholding

Toilet training

Changes in routine (i.e. travel)

School entry

Stressful life event

Celiac disease Hypothyroidism, hypercalcemia, hypokalemia Diabetes mellitus Dietary protein allergy Drugs, toxics Opiates, anticholinergics Antidepressants Chemotherapy Heavy metal ingestion (lead) Vitamin D intoxication Botulism Cystic fibrosis

8/7/2017

40

Hirschsprung Disease

Anal achalasia Colonic inertia

Anatomic malformations

Imperforate anus Anal stenosis

Pelvic mass (sacral teratoma) Spinal cord anomalies, trauma, tethered cord

Abnormal abdominal musculature (prune belly, gastroschisis, Down

syndrome) Pseudoobstruction (visceral neuropathies, myopathies,

mesenchymopathies) Multiple endocrine neoplasia type 2B

Constipation starting extremely early in life (<1 mo)

Passage of meconium >48 h

Family history of HD

Ribbon stools

Blood in the stools in the absence of anal fissures

Failure to thrive

Fever

Bilious vomiting

Abnormal thyroid gland

Severe abdominal distension Perianal fistula Abnormal position of anus Absent anal or cremasteric

reflex Decreased lower extremity

strength/tone/reflex Tuft of hair on spine Sacral dimple Gluteal cleft deviation Extreme fear during anal

inspection Anal scars

Sedentary lifestyle

Limited to no fiber intake

Decreased fluid intake (H20)

Medications

Medical condition affecting the anus or rectum

Family history of constipation

8/7/2017

41

History and physical

Digital rectal exam

Only Indicated in severe cases or directed by H&P

Abdominal radiography

Colonic manometry

Barium enema

Rectal Biopsy

Complete blood count

Celiac screening (IgA antibodies to tissue transglutaminase)

Urine analysis and culture

Thyroid stimulating hormone

Electrolytes and calcium

Blood lead level

Infants

Glycerin suppositories

Rectal stimulation

Apple, prune or pear juice 2-4 oz/day

Pureed Apples, prunes or pears

Multigrain or barley cereals

Pureed green peas

Foods high in fiber >3 g/ serving

Adequate water intake 32-64 ounces/day

Behavioral therapy for stool withholding

Toddler and Children

8/7/2017

42

Polyethelene glycol (Miralax) 0.4-0.8 g/ kg/ day, max 17 g/da

Lactulose 1 mL/kg po q day or bid, max 60 mL day

Sorbitol 1 mL/kg q day or bid, max 30 mL day

Senna

1.25-2.5 mL once or twice daily for 1-2 year olds

2.5-15 mL, from 2-12 and older

Bisacodyl ½ to 1 suppository once daily

Glycerin suppositories

1 suppository once daily

Metamucil ¼ to ½ teaspoon one to three times daily

Benefiber ¼ to ½ tablespoon one to three times daily

Citrucel ¼ to ½ tablespoon one to three times daily

8/7/2017

43

1. Muchowski, KE. Evaluation and Treatment of Neonatal Hyperbilirubinemia. Am Fam Physician, 2014 June 1; 89(11):873-878.

2. Jardine, LA., Woodgate, P. Neonatal Jaundice, Am Fam Physician. 2012 Apr 15;85(8):824-825.

3. Woodgate P, Jardine LA. Neonatal jaundice: phototherapy. Systematic review 319. BMJ Clinical Evidence. 2015 May. http://clinicalevidence.bmj.com/x/systematic-review/0319/overview.html. essed July 6, 2015.

4. BiliTool www.bilitool.org

5. AMERICAN ACADEMY OF PEDIATRICS: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Subcommittee on Hyperbilirubinemia. Pediatrics 2004; 114:1 297-316; doi:10.1542/peds.114.1.297. Downloaded at Columbia University on July 7, 2015.

6. Centers for Disease Control and Prevention. Kernicterus in Full Term Infants.http://www.cdc.gov/ncbddd/jaundice/hcp.html.

7. American Academy of Pediatrics. Jaundice picture. www.healthychildren.org. Jaundice picture.

8. Lauer, BJ, Spector, ND. Hyperbilirubinemia in the Newborn. Pediatrics in Review 2011; 32:341-349; (doi:10.1542/pir.32-8-341).

9. Lewis, ML. A Comprehensive Newborn Exam. Am Fam Physician. 2014 Sep 1;90(5):289-296.

10. Gastroesophageal Reflux. Pediatrics in Review Vol. 33 No. 6 June 1, 2012. pp. 243 -254 (doi: 10.1542/pir.33-6-243).

11. Lightdale, JR. Gremse, DA. Gastroesophageal Reflux: Management Guidance for the Pediatrician. SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION. Pediatrics Vol. 131 No. 5 May 1, 2013. pp. e1684 -e1695 (doi: 10.1542/peds.2013-0421). Last accessed July 7, 2015.

12. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for PediatricGastroenterology, Hepatology, and Nutrition (ESPGHAN) Journal of Pediatric Gastroenterology and Nutrition. 49:498–547#2009 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. http://www.naspghan.org/files/documents/pdfs/position-papers/FINAL%20-%20JPGN%20GERD%20guideline.pdf.

13. Hernanz-Shulman, Marta. Infantile Hypertrophic Pyloric Stenosis. Radiology 2003; 227:319 Published online before print 10.1148/radiol.2272011329.

14. Pandya,S. and Heiss,K. Pyloric Stenosis in Pediatric Surgery: An Evidence Based Review. June 2012. Impact Factor: 1. Surg Clin N Am. 92 (2012) 527–539 doi:10.1016/j.suc.2012.03.006 surgical.theclinics.com 0039-6109/12/$. .93 · DOI: 10.1016/j.suc.2012.03.006 · Source: PubMed.

15. The vomiting infant: pyloric stenosis. Paediatric Surgery. December 2013Volume 31, Issue 12, Pages 622–625. DOI: http://dx.doi.org/10.1016/j.mpsur.2013.09.002.

16. Krogh, C. et al. Bottle-Feeding and the Risk of Pyloric Stenosis Number 4, October 2012.www.pediatrics.org/cgi/doi/10.1542/peds.2011-2785 doi:10.1542/peds.2011-2785.

17. Wagner, Tamara. Bronchiolitis. Pediatrics in Review Vol.30 No.10 October 2009. 386-395. http://pedsinreview.aappublications.org/content/30/10/386.

18. American Academy of Pediatrics Practice Guideline. Diagnosis and Management of Bronchiolitis. Pediatrics. Volume 118, Number 4, October 2006. 1774-1793. www.pediatrics.org/cgi/doi/10.1542/ peds.2006-2223 doi:10.1542/peds.2006-2223.

19. Ralston et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. Volume 134, Number 5, November 2014;134:e1474–e1502.

http://www.surgeryjournal.co.uk/article/S0263-9319(13)00213-5/abstract

8/7/2017

44

20. Zoorob, R, Sidani, M. and Murray, J. Croup: An Overview. Am Fam Physician. 2011;83(9):1067-1073.

21. Canares, T et al. Going with the Flow: Respiratory Care in the Pediatric Emergency Department. Pediatric Emergency Medicine. Rhode Island Medical Journal. January 2014. 23-26.

22. Nierengarten,MB. Diagnosis and management of croup in children. Contemporary Pediatrics. March 1, 2015. http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/diagnosis-and-management-croup-children?page=full.

23. Immunization Action Coalition. http://www.immunize.org/catg.d/p4211.pdf.

24.e http://phil.cdc.gov/phil/details.asp?pid=3168. L accessed July 9, 2015.ters for Disease

Control and Prevention. Immunization Schedule. http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-ined-schedule.pdf . Last accessed July 9, 2015.

25. Cole S and Lanham J. Failure to Thrive: An Update. Am Fam Physician. 2011 Apr 1;83(7):829-834.

26. Kirkland, R, Motil K, Duryea, T. Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation. Up to Date. Last Updated Dec 01, 2015.

27. Kirkland, R, Motil K, Duryea, T. Failure to thrive (undernutrition) in children younger than two years: Management. Up to Date. Last Updated Dec 01, 2015.

28. Smitherman H and Macias J. Evaluation and management of the febrile young infant (7 to 90 days of age). Up to Date. Last Updated Sept 24, 2015.

29. Scarfone R and Cho C. Approach to the septic-appearing infant. Up to Date. Last UpdatedFeb 26, 2014.

30. Barson W. Community-acquired pneumonia in children: Clinical features and diagnosis. Up to Date. Last Updated Jun 08, 2016.

31. Barson W. Pneumonia in children: Inpatient treatment. Up to Date. Last Updated Jul 5 2016.

32. Stuckey-Schrock K, and Hayes B. Community-Acquired Pneumonia in Children. Am Fam Physician. 2012 Oct 1;86(7):661-667.

33. Weiner D. Emergency evaluation and immediate management of acute respiratory distress in children. Up to Date. Last Updated Nov 24 2014.

34. Nurko S and Zimmerman L. Evaluation and Treatment of Constipation in Children and Adolescents. Am Fam Physician. 2014 Jul 15;90(2):82-90.

35. Sood M. Constipation in infants and children: Evaluation. Up to Date. Last Updated May 12, 2016.

36. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 41 Failure to Thrive.2016.

37. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 102 Digestive System Disorders. 2016.

http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/diagnosis-and-management-croup-children?page=full

8/7/2017

45

38. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 109 Infections of the Neonatal Infant. 2016.

39. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 306 Major Symptoms and Signs of Digestive Tract Disorders. 2016.

40. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 172 Immunization practices. 2016.

41. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 176 Fever. 2016.

42. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 98 Clinical Manifestations of Diseases in the Newborn Period. 2016.

43. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 102.3 Jaundice and Hyperbilirubinemia in the Newborn. 2016.

44. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 71 Respiratory Distress and Failure. 2016.

45. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 329 Pyloric Stenosis and Other Congenital Anomalies of the Stomach. 2016.

46. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 355 Manifestations of Liver Disease. 2016.

47. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 391 Wheezing, Bronchiolitis and Bronchitis. 2016.

48. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 323 GERD. 2016.

Documents

AUGUST 25 -27, 2017 UPDATE Loews Chicago O'Hare Hotel ... · Bryon J. Lauer, and Nancy D. Spector Pediatrics in Review 2011;32:341-349 Increased production ABO incompatibility Red