Pediatrics/Pediatric Surgery
18.1 Bronchiolitis/RSV
Cause: Respiratory Syncytial Virus (RSV).
Epidem: Peak incidence from November-April. Major issue in immunocompromised, premature infants, and cardiopulmonary disease in peds < 2 yr of age (Jama 1999;282:1440).
Pathophys: Bronchial infection/reactivity.
Sx: Respiratory distress.
Si: Tachypnea with wheezing.
Crs: Refractory course despite β-agonist treatment almost defines this disease process; fever associated with more severe clinical course (Arch Dis Child 1999;81:231). Lifelong increased chronic course of airway hyper-reactivity in children if bronchiolitis after 1 yr of age (Am J Respir Crit Care Med 2000;161:1501), but this is not found if disease affects one only as an infant (< 12 mon of age) (J Peds 1999;135:8).
Cmplc: Respiratory failure.
Diff Dx: Adenovirus; parainfluenza virus; foreign body; pneumonia; human metapneumovirus (Nejm 2004;350:443); cystic fibrosis, if recurrent; occult bacteremia in children 2-36 months of age
is rare, and the approach of routine pan-culture is not supported by current literature (Arch Ped Adolesc Med 2004;158:671).
is rare, and the approach of routine pan-culture is not supported by current literature (Arch Ped Adolesc Med 2004;158:671).
Emergency Management:
Isolation—prevent nosocomial spread.
O2; iv fluids, if in extremis.
Nebulized racemic epinephrine (1 mg in 2 cc NS) in extremis (J Peds 1993;122:145) although routine use of 4 cc of 1% epinephrine nebulized with 3 treatments q 4 hr did not impact length of stay or ability of early for early discharge from hospital in those admitted (Nejm 2003;349:27).
Albuterol neb 2.5 mg per treatment or 10 mg/hr continuous.
Consider steroids (controversial)—parenteral, oral, or inhaled—parenteral study (Peds 2000;105:E44) vs budesonide inhaled study (Arch Dis Child 1999;80:343) and fluticasone inhaled study (Eur Respir J 2000;15:388).
Heliox (70:30 Helium:O2) may be of some benefit for both clinical severity score and need for ICU in those with moderate to severe symptoms—age group 1 mon to 2 yr (Peds 2002;109:68).
Nitric oxide data are equivocal (Intensive Care Med 1999:81).
Pediatrics consult for admit if not responding or stable, may need intubation +/− aerosolized ribavirin as inpatient—con (Am J Respir Crit Care Med 1999;160:829).
18.2 Cat-Scratch Disease (a Form of Cervical Adenitis)
Cause: Bartonella (Rochalimaea) henselae and quintana, a small pleomorphic Gram negative, probably rickettsial organism. Sometimes Afipia felis (J Clin Microbiol 1998;36:2499).
Cervical adenitis itself is usually a self-limited viral (adenovirus, enterovirus, CMV, Epstein-Barr, herpes simplex) disease which resolves quickly, but can be caused by Staphylococcus, Streptococcus, and anaerobes (Clin Peds (Phila) 1980;19:693); less likely anaerobes, atypical organisms, cat-scratch disease, and toxoplasmosis.
Epidem: From young cats, infected for a few weeks; transmit via bites, scratches, and fleas, thus common name is a misnomer. 80% of cases in pts under age 21.
Pathophys: 7-14 d incubation. Bartonella spp. also found in bacillary angiomatosis and bartonellosis (Int J Dermatol 1997;36:405).
Sx: Bite or scratch from kitten (90% positive); papule at site of scratch.
Si: Fever; signs of scratch or bite with papule noted; adenopathy with 40% of nodes suppurative; potentially many ocular findings including Parinaud’s oculoglandular syndrome (infection of eye surface and regional lymphadenopathy) (Curr Opin Ophthalmol 1999;10:209).
Crs: Usually self-limited, even with complications.
Cmplc: Encephalopathy (J Peds 1999;134:635); encephalitis (10%); osteolytic bone lesions; conjunctivitis; purpura; mesenteric adenitis.
Immunocompromised patients: disseminated disease; bacillary angiomatosis—looks somewhat like Kaposi’s sarcoma; peliosis hepatitis—sometimes seen in the immunocompetent.
Diff Dx (rare): TB and other mycobacterium (Clin Peds (Phila) 1997;36:403); Haemophilus influenzae; syphilis; fungal; Yersinia pestis.
Lab: CBC with diff showing mild eosinophilia; ESR; liver function tests, if systemically ill; obtain CSF, if neuro changes and look for increased protein; Rochalimaea henselae titer of > 1:64 is 84% sensitive and 96% specific. PCR may be needed (Hum Pathol 1997;28:820).
Emergency Management:
Mild disease (only papule at site):
No rx, outpatient follow-up in 2-3 d with primary physician.
Moderate/severe disease:
Ciprofloxacin 500 mg po bid; or azithromycin 500 mg d 1 followed by 250 mg d 2-5 (pediatrics—10 mg/kg d 1 followed by 5 mg/kg d 2-5) (Ped Infect Dis J 1998;17:447)
Erythromycin 500 mg po qid for disseminated forms; second line is Doxycycline 100 mg po bid.
May also consider gentamicin, ceftriaxone, cefotaxime, or amikacin.
Primary care consult for admission, if moderate or severe disease.
18.3 Child Abuse
Cause: Potentially anyone—parents, caregivers, strangers.
Epidem: Linked to parental unemployment/poverty, especially fathers (Child Abuse Negl 1998;22:79). Adolescent mothers at higher risk than older counterparts, especially if they had been abused (Child Abuse Negl 2000;24:701). False allegations or misinterpretation uncommon (2.5%) (Child Abuse Negl 2000;24:149).
Pathophys: Abuse or neglect in the physical, sexual, or emotional (verbal) realm.
Sx: Sleep disorders; nightmares; inappropriate sexual play; school and developmental problems; phobias; depression.
Si: Delay in seeking rx. Recurrent injury; patterned bruises; fractures; head injuries; retinal hemorrhages; facial and oral injuries (Child Abuse Negl 2000;24:521). Injuries inappropriate for age, not consistent with hx, and to different body planes.
Crs: Potentially fatal; intervention requires a team approach with state agencies, police, social work, and other specialty organizations.
Cmplc: Failure to thrive; may impact all aspects of life, including long-term neurobehavioral problems (J Child Psychol Psychiatry 2000;41:97).
Lab: Consider radiographic bone survey if evidence of trauma (J Am Acad Orthop Surg 2000;8:10); forensic photos.
Emergency Management:
Pediatrics consult for admission.
Department of health/human services referral.
18.4 Croup
Cause: Parainfluenza virus, and others.
Epidem: 3:100 under age 6 yr; 1.3% must be hospitalized; adult croup does exist (Chest 1996;109:1659).
Pathophys: Two forms, and both occur mainly at night with child in recumbent position—whether this is due to fluid shifts with consequent edema or meridian causality is unknown.
Acute laryngotracheitis—follows 2-3 d of URI.
Spasmodic croup—no antecedent illness; acts like hypersensitivity syndrome.
Sx: Barky cough.
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