Patient Presentation
A 10-year-old male came to the emergency room with a history of 24 hours of fever, chills, muscle aches, headache, rhinorrhea and cough. The cough was described as wet and would come frequently but had not caused spasms of coughing. He was now having chest pain and had coughed up blood twice in the past hour. The parents described it as soaking his pillowcase with a 5 inch circle of blood. They said it was fresh blood and did have some mucous in it. They described it as like a spot for a nosebleed only larger. The patient said that the fluid had come out of his mouth and not his nose. He also said that since this had happened he had been more nauseated.

The past medical history showed no bruising or bleeding problems, no pulmonary problems and he had otherwise been well. He was current with his immunizations but had not yet received his seasonal influenza vaccine.
The family history was negative.

The pertinent physical exam showed an anxious male sitting up. His heart rate was 94/min, respiratory rate of 32/min and mildly dyspneic, blood pressure 102/60, pulse oximeter of 89-91% on room air. His eyes were glassy. His nose had copious clear rhinorrhea that was also seen in oropharynx. His oropharynx was normal. His lungs had diminished breath sounds at the bilateral bases. There was no wheezing, rales or rubs noted. There was no tracheal tugging but there were some mild intercostal retractions. He said that his sternum hurt with coughing and was reproducible on exam. He had no other areas of chest pain. His heart, abdomen and rest of his examination was normal.

The diagnosis of probable hemoptysis in the setting of an acute respiratory illness was made. He was started on oxygen by face mask with improvement of his oxygenation to low 90s. The radiologic evaluation of a chest radiograph showed prominent interstitial markings at the bases but no obvious focal infiltrate. The laboratory evaluation included a complete blood count which had increased lymphocytes, his C-reactive protein and erythrocyte sedimentation rate were mildly elevated. His bleeding profile and urinalysis were normal. A respiratory viral panel was positive for Influenza A. The patient’s clinical course revealed that he was started on anti-viral medication, continued oxygen and monitored closely. Pulmonary medicine was consulted and had no specific additional recommendations. Critical care medicine was made aware of the patient in case he had a decompensation. Over the next 24 hours he had two more episodes of hemoptysis that were smaller in volume each time. He continued to need oxygen for 3 days and was discharged home on the 4th day.

Discussion
True hemoptysis is a very uncommon or rare problem in pediatrics but can be potentially life-threatening. Massive hemoptysis has a high mortality (up to 50%) mainly from asphyxia and inability to ventilate and oxygenate the patient because of blood in the pulmonary airways. Fortunately, most hemoptysis is small in amount that resolves within 24 hours.

Initial evaluation for hemoptysis can include complete blood count, coagulation studies, C-reactive protein, erythrocyte sedimentation rate, urinalysis (possible pulmonary-renal problems), radiographic imaging including chest x-ray and/or computed tomography, and sputum studies. Treatment depends on the underlying cause and severity. Active significant bleeding and any evidence of cardiopulmonary compromise is treated aggressively. This may include bronchoscopy, ventilatory management and possible surgical treatment. Antibiotics are commonly prescribed as this is a common cause.

Learning Point
Data about the epidemiology of hemoptysis is hard to determine as it is uncommon and the causes are quite diverse. Infection is considered the primary cause but other/unknown cases also are common as a broad category. Anatomic abnormalities can be hard to identify but can cause some of the most severe bleeding and/or complications. Bleeding from other sites may cause the parent to believe the child has hemoptysis when in reality they have epistaxis or have bitten their tongue or cheek.

Causes of hemoptysis include:

• Infection – most common reason thought to be about ~1/3 of the cases
  • Pneumonia – bacterial, viral, fungal
  • Laryngitis
  • Lung abscess
  • Tracheobronchitis
  • Tuberculosis
• Bleeding from other sites
  • Nasopharyngeal – trauma especially to oronasal structures
  • Esophagitis
  • Gastrointestinal
  • Granulation tissue
  • Swallowed maternal blood
  • Tracheostomy
• Bronchiectasis
  • Cystic fibrosis
  • Ciliary dyskinesia
• Cardiac and vascular anomalies
  • Congenital heart disease
  • Hemangioma
  • Hereditary telangectiasia
  • Pulmonary arteriovenous malformations
  • Pulmonary embolism
  • Pulmonary hypertension
• Drug Toxicity
• Factitious hemoptysis
• Foreign body aspiration
• Idiopathic pulmonary hemosiderosis
• Tumor
  • Adenoid
  • Carcinoid
• Vasculitis
  • Goodpasture syndrome
  • Henoch-Schonlein purpura
  • Microscopic polyangiitis
  • Systemic lupus erythematosus
  • Wegner granulomatosis or granulomatosis with polyangiitis

Questions for Further Discussion
1. What are indication for intubation?
2. How is acute pulmonary hemorrhage treated if it is cardiovascular compromising?
3. What are the advantages and disadvantages of different types of bronchoscopy?
4. What is the role of surfactant in the lung?
5. What are the complications of Influenza?

Related Cases

Disease: Pulmonary Hemorrheage | Hemoptysis | Influenza | Lung Diseases

Symptom/Presentation: Fever and Fever of Unknown Origin | Respiratory Distress

Specialty: Critical Care | Emergency Medicine | Infectious Diseases | Allergy / Pulmonary Diseases

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Bleeding, Respiratory Failure and Influenza.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Bannister M. Paediatric haemoptysis and the otorhinolaryngologist: Systematic review. Int J Pediatr Otorhinolaryngol. 2017;92:99-102. doi:10.1016/j.ijporl.2016.10.021

Simon DR, Aronoff SC, Del Vecchio MT. Etiologies of hemoptysis in children: A systematic review of 171 patients. Pediatr Pulmonol. 2017;52(2):255-259. doi:10.1002/ppul.23497

Shnayder R, Needleman JP. Hemoptysis. Pediatr Rev. 2018;39(6):319-321. doi:10.1542/pir.2017-0157

Yang J, Liu F, Liang Y, Guo C, Wang J, Chen X. Massive Hemoptysis in Children. Can Respir J. 2020;2020:6414719. doi:10.1155/2020/6414719

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 5-day-old female came to clinic for their routine health supervision visit after birth. The baby was a term infant born to a 31 year old G1P1 female without problems during the pregnancy or delivery. The baby was breastfed and was doing well. The infant was not jaundiced and was eliminating well.

The pertinent physical exam showed a 3.148 kg infant (25% overall, down 5% from birthweight), length 50 cm (50%), head circumference 35 cm (50%). There was mild facial jaundice without icterus (transcutaneous bilirubin was 6.9 mg/dL) and the rest of the examination was normal.

The diagnosis of a healthy female was made. The pediatrician discussed anticipatory guidance and recommended the family obtain some Vitamin D to supplement the baby. The mother said that she was Vitamin D deficient and was already taking some supplements. She wanted to know that if she kept taking her own supplement and also gave the baby Vitamin D would that give the baby too much Vitamin D. The pediatrician said that he wasn’t sure, but that the easiest thing to do was to just switch the mother to taking her own supplement of 6400 IU of Vitamin D daily and then that would help the mother and would be the recommended dosage for the baby.

Discussion
Vitamin D is an important vitamin for bone formation and mineral homeostasis. Hypocalcemia, hypophosphatemia, osteomalacia, rickets and tetany can all result because of Vitamin D deficiency. Deficiency is caused by inadequate dietary intakes of Vitamin D, inadequate exposure to sunlight or patients with fat malabsorption or renal disease. Even in high sun exposure areas of the world, Vitamin D deficiency can occur because of inadequate exposure due to clothing or cultural practices. Sunscreen blocks sunlight and an SPF (sun protection factor) of 8 blocks 95% of the sun, so there needs to be a careful balance between over- and under- sun exposure also. Adequate sunlight exposure for infants is considered 30 minutes/week clothed in a diaper only, or 2 hours/week fully clothed but without a hat.

25-hydroxy Vitamin D (25(OH)D or calcidiol) is the best indicator of Vitamin D status. More than 15 ng/mL is considered adequate Vitamin D serum levels. For a review of the production of Vitamin D, click here. For a review of how much Vitamin D is in different foods, click here.

Human breast milk is low in Vitamin D. Therefore all infants who are exclusively breastfed need supplementation. Infants with darker pigmentation or living in northern climates with less sunlight are particularly susceptible to Vitamin D deficiency. This supplementation can be stopped if the infant is taking at least 1 liter or quart/day of formula or Vitamin D fortified whole milk. Children taking less than 1 liter/day of Vitamin D fortified milk should also receive supplementation of 400 IU/day. Note that soy milk may or may not be Vitamin D fortified. Breastfeeding women who wish to take their own supplement are recommended to take at least 6400 IU.

Learning Point
A meta-analysis and systematic review of a “…dose-response analysis on the relation[ship] between circulating 24-hydroxy vitamin D … and maternal [v]itamin D supplementation in mother-infant dyads…”” was conducted in 2022. They found that “maternal [v]itamin D supplement dosages were associated with circulating 24(OH)D concentrations in breastfeeding women in a nonlinear fashion.” In contrast, “A linear relation was observed between maternal [v]itamin D supplementation dosage and the infants’ circulating 25(OH)D concentrations. Each additional 1000 IU of maternal [v]itamin D intake was accompanied by a 2.7 ng/mL increase in serum 25(OH)D concentration in their nursing infants.” They also found that “[l]ong-term maternal supplementation with vitamin D at a high dose (>6000IU/d) effectively corrected vitamin D deficiency in both mothers and infants.” As many mothers are Vitamin D deficient, this appears to be a good treatment for both mother and baby.

Questions for Further Discussion
1. What are the recommendation for supplementing iron to infants and young children?
2. How much calcium is recommended for different ages of the pediatric population?
3. What are the recommendations for supplementing late pre-term infants?

Related Cases

Disease: Vitamin D Supplementation | Vitamins

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: General Pediatrics | Neonatology | Nutrition / Dietetics

Age: Newborn

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vitamin D Deficiency and Vitamin D.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Rios-Leyvraz M, Yao Q. Calcium, zinc, and vitamin D in breast milk: a systematic review and meta-analysis. Int Breastfeed J. 2023;18:27. doi:10.1186/s13006-023-00564-2

Niramitmahapanya S, Kaoiean S, Sangtawesin V, Patanaprapan A, Bordeerat NK, Deerochanawong C. Correlation of 25-Hydroxyvitamin D Levels in Serum vs. Breastmilk in Vitamin D-Supplementation Breastfeeding Women during Lactation: Randomized Double Blinded Control Trial. J Med Assoc Thail Chotmaihet Thangphaet. 2017;100 Suppl 1:S165-171.

Kazemain E, Ansari S, Davoodi SH, et al. The Effect of Maternal Vitamin D Supplementation on Vitamin D Status of Exclusively Breastfeeding Mothers and Their Nursing Infants: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Adv Nutr. 2022;13(2):568-585. doi:10.1093/advances/nmab126

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 2-year-old male came to clinic after a witnessed fall at daycare. What the daycare professional told the mother was that he was jostled by another child and fell striking his face on the side of a plastic kitchen set. He cried immediately and was consoled within a reasonable time frame. He did not lose consciousness and had had normal mentation since the episode 3 hours previously. He had slept at his normal nap time but was awoken early from his nap to come to the appointment. He had a cut lip that had bled for a short time and resolved with pressure and some ice. He had been given some acetaminophen and drunk fluids without emesis. There was no reported drainage from nose or ears. The daycare had not commented on his head, eyes or neck or other body problems. The mother said he was acting normally but she was concerned about the swelling of his lip and also a small abrasion and redness on his nose. She was concerned that he had broken his nose.

The pertinent physical exam had normal vital signs and growth.
Head had no abnormalities. His face showed a small abrasion from the tip upward for about 1/3 of the nose. It was clean and dry without erythema and no edema. There was also a 2-4 mm abrasion on his chin. His eyes revealed extra ocular movements to be intact. External structures were without abrasions and gross visual acuity was normal. His ears had no fluid behind the tympanic membranes. His nose showed no evidence of external deformity without any malpositioning or pain with palpation. There was no abnormal bleeding or masses. His nasal septum appeared intact. His mouth showed a small 5 mm laceration on the lower lingual surface with good hemostatis and localized edema. The same area on the external surface also had some mild edema. There was no other evidence of oral trauma. His neck was without pain and had normal ROM. He had normal mental status throughout the visit.

The diagnosis of a small lip laceration and facial abrasions after a witnessed fall was made. The mother was counseled about how to manage the lip laceration, and was relieved to hear that a nasal fracture was very unlikely in his case. The mother was given head injury instructions and asked to monitor for any additional problems that arose for his nose or mouth too.

Discussion
Facial trauma is common and accounts for about 11% of all pediatric emergency room visits. Nasal fractures are fewer in younger ages but increase in incidence as children age because of increased opportunity for trauma (e.g. playing, sports, car accidents, etc.). Anatomy also plays a part as young children have more cartilaginous structures and the nose does not protrude as much as an older child or adult who also have more osseous structures. The nasal structures have 2 bigger growth phases from 2-5 years and also at puberty. Adult size is reached in 16-18 years for females and about 2 years later for males (18-20 years). Fractures in children could cause problems with ability to breath and altered growth.

History should include the mechanism of injury, its intensity and timing, along with other potential associated problems such as head and neck, dental or ocular injuries of the head and neck, or other body parts. As with all trauma, ABCs should be carried out and investigating for additional injuries is important. Head and neck structures should be evaluated for any trauma. The neck should be examined for pain, masses and range of motion (if appropriate). Eyes should be examined for symmetry, pupillary reflexes, extra ocular movements and acuity. Racoon eyes or other ecchymosis around the eyes may indicate basilar skull or other cranial fractures. Ear examination showing any trauma including hemotympanum should be evaluated for cranial fractures. Dental examination should look for any loose teeth or intraoral trauma, including the temporomandibular junction. Neurological examination should evaluate the cranial nerves, gait, balance etc. Other body structures should be evaluated based on the history.

With nasal trauma the airway patency and nasal airflow are important to determine as the airway is more collapsible and also narrower in the pediatric patient. The external nose should be inspected for obvious deformations, edema, erythema, and bruising. Internally, the nasal septum should be evaluated to make sure there is no septal hematoma that needs to be addressed emergently. Septal hematomas are rare but more common in children. Other nasal structures should be evaluated using adequate lighting and nasal speculum. Airflow in both nares should be determined but can be difficult to do in children. Epistaxis is common but not for every injury. Nasal fractures generally occur with epistaxis, but are not specific for it. Blood clots may make the internal examination difficult to complete as well. Other drainage should be asked about and inspected for. Cerebrospinal fluid leaks should try to be discerned but can be difficult to discern, especially in children who often have concomitant upper respiratory infections.

Learning Point
In general, low impact, limited acute nasal trauma, without significant signs or symptoms for the patient (especially possible septal hematoma and/or airway obstruction), and no evidence of significant additional trauma usually, but not always, are self limited and are not because of a nasal fracture. These patients are usually treated symptomatically with ice, pain medications and return precautions for any nasal/airflow obstruction, additional bleeding or nasal discharge and head injury precautions. Sometimes subtle deviation or obstruction only becomes apparent in the next several days after the trauma as the edema may distort the structures.

Patients who cannot be effectively examined by a primary care or emergency room physician or if there is concern for additional or more significant injuries should consult an otolaryngologist for further evaluation and treatment. This could include head and facial imaging. Patient with acute nasal fracture ( 3 months) are treated with open reduction and possible septoplasty if airway flow is compromised. Timing of the surgery depends on the clinical circumstances. Septoplasty is used sometimes for various bony deformities in chronic/delayed cases.

Questions for Further Discussion
1. What are indications for head imaging after a traumatic injury?
2. How is epistaxis treated?
3. How is dental trauma treated?
4. What causes facial pain? A review can be found here

Related Cases

• Disease: Lip Laceration and Facial Abrasions |

Nose Disorders

• |

Facial Injuries and Disorders

• Symptom/Presentation:

Mass or Swelling

• |

Trauma

• Specialty:

Dentistry / Orthodontia

• |

Emergency Medicine

• |

Otolaryngology

• Age:

Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Nose Injuries and Disorders and Facial Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Landeen KC, Kimura K, Stephan SJ. Nasal Fractures. Facial Plast Surg Clin N Am. 2022;30(1):23-30. doi:10.1016/j.fsc.2021.08.002

Tolley PD, Massenburg BB, Manning S, Lu GN, Bly RA. Pediatric Nasal and Septal Fractures. Oral Maxillofac Surg Clin N Am. 2023;35(4):577-584. doi:10.1016/j.coms.2023.04.005

Trujillo O, Lee C. Nasal Fractures: Acute, Subacute, and Delayed Management. Otolaryngol Clin North Am. 2023;56(6):1089-1099. doi:10.1016/j.otc.2023.05.004

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 2-year-old female came to clinic for her well child care. Her parents had no concerns except they had noted a “bump” in the middle of the roof of her mouth. They were not sure how long it had been there for, but had noticed it about 2 weeks previously when they were brushing her teeth. It hadn’t changed over time and didn’t seem to bother her.

The past medical history was non-contributory. She had seen a dentist twice in her life whom the parents said had no concerns.

The pertinent physical exam noted a happy toddler with normal vital signs and growth around 50%. Her oral examination was difficult to perform because she would refuse to open her mouth adequately. The lesion was estimated to be about 10 mm in size, slightly elevated from the surrounding palatal structures and was midline close to the hard and soft palate interface. The lesion appeared to have normal mucosa covering it. Surrounding erythema or ulcerations could not be determined. The rest of her oral cavity could not be examined. Her neck had some shotty anterior cervical nodes but no significant adenopathy. Her face appeared normal without obvious lesions or masses externally. The rest of her examination was normal.

The diagnosis of a probable benign lesion was made but the pediatrician was not certain because she could not examine the area fully. She recommended to make an appointment with the patient’s dentist. The dentist saw her 1 week later and confirmed this was a torus palatinus or a benign exostosis.

Discussion
Exostoses are dense cortical nodular osseous structures that are benign but which can cause problems due to size or location. The tissue grows outward from the bone. Long bone locations are common.

Bone spurs are a common exostosis that is specifically an osteophyte as it occurs along a joint margin. Enthesophytes are benign bony projections from the tendon or ligament insertion. Some exostoses have specific names such as Surfer’s ear (occurring in the ear canal) or Haglund’s deformity (or pump bump) that occurs on the back of the heel. People with hereditary multiple exostoses have multiple exostoses that often occur around the knee. It occurs in 1:50,000 people.

Learning Point
Oral exostoses are named for their location. Torus palatinus is located midline on the hard palate. Torus maxillaris which is usually located bilaterally along the buccal and palatal bony shelves in posterior molar areas. Torus mandibularis which are located bilaterally along the mandibular lingual cortical plate. Palatal and maxillary locations are more common. As they are bony and have normal oral mucosa overlying them they may appear yellow or whitish. They usually do not require treatment unless they cause functional problems (e.g. has a crevice that food becomes trapped in and could have risk for aspiration of the food) or needing orthodontic or prosthodontic treatment and the prosthesis would rub on the tori if not recontoured.

Oral exostoses are an anatomical variation. The prevalence varies in different populations significantly with torus palatinus occurring in 1.4% – 66% with high rates (most quote 20-30% overall) in Asians, and Eskimos people. It is thought that the condition’s cause is multifactorial with increased risk also because of trauma, hypermasticatory activities and possible Vitamin D or other diet related factors. The differential diagnoses includes other oral growths including “…fibromas, mucoceles, osteomas, osteochrondromas, and osteoid osteomas.” They do not appear to have increased risk of malignant transformation but can grow with age.

Questions for Further Discussion
1. What common lesions occur in newborn infants’ oral cavities?
2. What are the guidelines for initiation of routine dental care in infants and young children?
3. What treatment can be offered for people with exostoses in non-oral body locations?

Related Cases

Disease: Torus Palatinus | Child Dental Health | Bone Diseases

Symptom/Presentation: Mass or Swelling

Specialty: Dentistry / Orthodontia | Orthopaedic Surgery and Sports Medicine

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Bone Diseases and Child Dental Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Yildiz E, Deniz M, Ceyhan O. Prevalence of torus palatinus in Turkish schoolchildren. Surg Radiol Anat SRA. 2005;27(5):368-371. doi:10.1007/s00276-005-0003-x

Chatterjee S. Bony bumps in the mouth. Cleve Clin J Med. 2016;83(1):17-18. doi:10.3949/ccjm.83a.15033

Aron J, Raithel SJ, Mannes AJ. Torus Palatinus and Airway Management. Anesthesiology. 2017;127(1):164. doi:10.1097/ALN.0000000000001566

Akintoye SO, Mupparapu M. Clinical Evaluation and Anatomic Variation of the Oral Cavity. Dermatol Clin. 2020;38(4):399-411. doi:10.1016/j.det.2020.05.001

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa