Patient Presentation
A 17-month-old male was admitted for nutritional resuscitation. According to records, his weight tracked around the 3rd percentile for the first 6 months of life, and his height as 25-50%. At 14 months his weight was 50% for a 5 month old, height was 50% for a 9 month old and head circumference was 50% for a 6 month old. He had a complex social situation and was currently in foster care. Unfortunately there were ongoing problems with the foster care placement also. The social worker who brought him to clinic earlier in the day stated that he takes 3 meass and 5 cans of Pediasure®/day per foster care. There is no history of emesis, reflux, diarrhea, constipation, or food refusal. The past medical history showed that he was a full term infant with no problems prenatally or postnatally and his mother received routine prenatal care. He had a previous evaluation by a feeding/speech and language specialist that found no problems with oromotor feeding or swallowing but was severely delayed in speech. He was receiving speech therapy. He had had an extensive laboratory evaluation in the specialty nutrition clinic at 15 months of age, that showed no obvious cause of his poor growth. The family history showed that his mother’s height is 4 foot 10 inches, and father is 5 foot 7 inches. There are family members with developmental delay, hypothyroidism, and learning problems.

The pertinent physical exam shows a small, thin child with little subcutaneous fat. He is smiling and interactive, but he only babbles consonants and vowels without recognizable words. Gross motor and fine motor skills appear normal for age. His weight was 7.84 kg (50% for a 6 month old), height was 74.5 cm (50% for a 12 month old) and head circumference was 45 cm (50% for an 8 month old). This was only 1 g/day weight gain since his last visit. His physical examination was normal otherwise. The diagnosis of failure to thrive with failed outpatient management, language developmental delay and a complex social situation was made. The patient was started on a general toddler diet with strict calorie count which included 6 small meals and 3 servings of Pediasure®/day. He had no water or juice and a total of 25 minutes maximum time allotted for all meals. A behavorial psychologist also worked with him regarding feeding. Speech continued his therapy. The patient’s clinical course showed that he was eventually discharged back to his biological parents with community social service support. He continued to have some problems with feeding over the next 3 years. Consistent calorie boosting at home and daycare caused him to regain and stabilize his weight and height at the 5th percentile. His clinical course also showed a growth pattern consistent with genetic short stature in addition to the resolving failure to thrive.

Discussion
Failure to Thrive (FTT) is defined as persistent weight below the 3rd percentile for age in infants and young children. The associated terms “Failure to gain weight” (FGW) or “Lack of Normal Physiologic Growth and Development” are more precise, especially for children who are not below the 3rd percentile but are losing weight over time and/or crossing percentile lines on their growth curve. For general growth parameters see How Do I Calculate Mid-Parental Height and Other Growth Parameters? About 70-80% of FTT cases have psychosocial problems that are associated with the FTT or the primary cause of the FTT. Children of older ages may also have FTT such as those with psychosocial dwarfism or eating disorders.

Children with FTT have a wide range of appearances from ill and emaciated to well but small, depending on the cause. History and physical examination are the mainstay of diagnosis. A detailed nutritional history including caloric assessment, who feeds the child, type of food offered, when/where food is offered, and weaning are important. Birth history (including possible teratogens and substance abuse), developmental history(including loss of milestones for possible metabolic or genetic abnormality), and past medical history for chronic infections or other medical problems. Family history should including miscarriages or early childhood deaths and also weight/height of parents and siblings (for possible genetic abnormalites). Social history including exploration of stressors are very important. A complete physical examination (including accurate weight, height and head circumferences and their trends) with directed emphasis in areas clued by the history is important. Laboratory evaluation should be limited and guided by the history and physical examination. It should also be staged.

Initial clinical evaluation may include:

• Albumin
• CBC, Differential, Platelet count
• ESR, C-Reactive Protein
• Electrolytes, BUN, Creatinine
• PPD with Control
• Total Protein
• Urinalysis and Urine pH
• Stool Guiac (consider fecal fat, stool Clinitest)
• Dietary Consultation

Other tests which may be ordered depending on clinical suspicion include:

• ALT, AST
• Calcium, Phosphorus
• HIV/AIDS
• Iron Studies
• Lead
• Thyroid Function Tests
• Quantitative Immunoglobulins
• Urine for Reducing Substances, Culture
• Stool for Malabsorption
• Stool for Ova and Parasites
• Bone Radiographs
• Chest Radiograph
• Neuroimaging
• Sweat Test
• Cardiac Evaluation

Treatment depends on the probable underlying cause of the FTT. If nutritional deficiencies are indicated, appropriate dietary counseling and supplementation are needed. Counseling for psychosocial stressors in the caregivers (and patient) may also be appropriate. Other specific treatments will vary. Patients should be hospitalized for severe malnutrition or dehydration, extreme parental anxiety, or failure of outpatient treatment.

Learning Point
The differential diagnosis of failure to thrive includes:

• Chronic Disease
  • Cardiac
    • Cardiac Failure
  • Neoplasia
  • Pulmonary
    • Bronchopulmonary Dysplasia
    • Cystic Fibrosis
  • Renal
    • Renal Failure
    • Renal Tubular Acidosis
  • Rheumatology
    • Systemic Lupus Erythematosus
• Congenital/Genetic/Neurological Disease
  • Cerebral Palsy
  • Craniofacial Abnormalities
  • Fetal Alcohol Syndrome
  • Intrauterine Growth Retardation
  • Mental Retardation
  • Myopathies
  • Neurocutaneous Syndromes
    • Neurofibromatosis
  • Prematurity
  • Primary CNS abnormality
  • Genetic Syndromes
    • Cystic Fibrosis
    • Russell-Silver Syndrome
    • Williams Syndrome
  • Muscle weakness
    • Prader Willi Syndrome
  • Inborn Error of Metabolism
• Endocrinological Disease
  • Diabetes Mellitus
  • Hypopituitarism
  • Hyperthyroidism
  • Growth hormone Deficiency
• Gastrointestinal Disease
  • Celiac Disease
  • Chronic Diarrhea
  • Chronic Emesis
  • Esophagitis
  • Gastrointestinal Reflux
  • Inflammatory Bowel Disease
  • Malabsorption
  • Protein Losing Enteropathies
• Infectious Disease
  • Congenital infections
  • HIV/AIDS
  • Recurrent infections
  • Parasites
  • Tuberculosis
• Immunological/Rheumagological Disease
  • Immunodeficiencies
• Other
  • Anemia
  • Heavy Metals
    • Lead
    • Drugs
      • Amphetamine
      • Cocaine
      • Hydantoin
      • Phenobarbital
  • Dental Caries
• Nutritional Problems
  • Inadequate Calories
  • Inadequate Protein
  • Poor Appetite
  • Maternal Malnutrition
• Psychiatric Problems
  • Depression
  • Eating Disorders in Patient or Mother
  • Munchausen’s Disease by Proxy
  • Psychosis
• Social Problems
  • Child Abuse
  • Caregiver/Child Interaction Abnormalities
    • Emotional Deprivation
    • Difficult Child
  • Family Stress
  • Parenting, Ineffective
  • Poverty

Questions for Further Discussion
1. What is the differential diagnosis for short stature?
2. What signs, symptoms or testing may help to distinguish between failure to thrive versus low weight in a child with a chromosomal abnormality?
3. What social services are available locally to assist families with failure to thrive children?

Related Cases

Disease: Failure to Thrive and Lack of Normal Physiological Growth | Growth Disorders | Infant and Toddler Nutrition

Symptom/Presentation: Developmental Delay | Failure to Thrive and Lack of Normal Physiologic Growth

Specialty: General Pediatrics | Nutrition / Dietetics | Social Services

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, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Growth Disorders and Infant and Toddler Health.

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

To view images related to this topic check Google Images.

Kleinman RE, edit. Pediatric Nutrition Handbook. American Academy of Pediatrics. 6th edit. 2009;601-636.

El-Baba MF, Bassali RW, Benjamin J, Mehta R. Failure to Thrive. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/985007-overview (rev. 5/4/09, cited 12/10/09).

ACGME Competencies Highlighted by Case

Patient Presentation
A 7-year-old male came to clinic for his health supervision visit. His mother noted that over the 2nd grade school year he seemed to be having more problems with reading and the teachers noted that he had more inattention in the afternoon when they did language arts.
He had been previously diagnosed with attention deficit hyperactivity disorder (ADHD) in kindergarten. She said that otherwise he was his energetic self and that the teachers didn’t complain of other behaviors.
The teachers had not done any specific evaluations that the mother was aware of.
The past medical history showed a healthy male with an unremarkable past medical history ADHD that was diagnosed after parent and teacher evaluations, a psychosocial assessment and normal hearing, vision and laboratory screening. He had done well in school and home with some behavioral modification.
The family and social history showed the father was described as “energetic” and had had some difficulties reading as a child. He graduated from college and was a businessman with steady employment. Other paternal relatives were described as “energetic” also.
There were no recent medical or psychosocial changes in the family. There were no mental illness reported in the families.
The review of systems was negative.

The pertinent physical exam showed a healthy 7 year old with normal growth parameters and vital signs. His examination was negative except that he was very verbal in the office describing his school and after-school activities.
The work-up included a fuller interview with the patient who said that he liked school, had friends, and denied bullying or other problems at school or home. He said that he didn’t read as well as most of the other kids and found it hard to pay attention to the reading.
The diagnosis of a possible learning problem in addition to the ADHD was made but the pediatrician suggested that he be re-screened for vision and hearing problems that may not have been picked up previously.
She suggested that the school may also want to do some basic cognitive testing in addition to specific educational testing.
The patient’s clinical course showed that he was found to have an average to above average intelligence quotient, but was borderline for his age in reading skills.
He started a special reading program in the regular classroom and was making good progress by the end of the school year. Over the summer, the family was gong to do extra reading with him.

Discussion
Attentional problems are a clinical diagnosis.
Some people use a functional definition of attentional difficulties that disrupt the normal activities of the patient and/or family.
Attention Deficit Disorder (with or without hyperactivity, i.e. ADD, ADHD) has specific criteria for its diagnosis using the Diagnostic and Statistical Manual (version IV).

Children with attentional problems present in a wide variety of ways, including poor school performance, behavioral problems, personality changes, and inappropriate or antisocial behavior. History is very important and should include school history with results of other evaluations, typical day activities and behaviors, birth history (including possible teratogens and substance abuse), developmental history (including possible loss of milestones), social history including use of discipline and possible abuse, and family history (including learning disabilities, mental illness and genetic abnormalities).
Family members impressions of strengths, weaknesses, and if the child reminds them of another family member are often revealing.
ADD/ADHD can exist alone, be co-morbid or be mistaken for another problem. Co-morbid conditions include various developmental disorders (including learning disorders), anxiety disorders, conduct disorder, oppositional defiant disorder, and mild mental retardation.
Physical examination should include a thorough neurological examination for subtle or overt neurological abnormalities (for immaturity or gross abnormality of the CNS, and sensory deficits).
The evaluation should include an extensive history and physical examination, vision and hearing testing (for sensory deficits), academic assessment including observations from classroom teachers (for learning disabilities), and psychological screening (for psychological/social assessment).
Parental observations by structured questionnaires may reveal other information not gathered by interview.
The initial evaluation may necessitate further workup with cognitive testing (for mental retardation), EEG (for seizures), blood testing (for substance abuse, lead, hyperthyroidism), etc.

Treatment depends on the underlying cause. Often, acknowledgment of the problem and appropriate educational, psychological, and social supports will improve the attention of the child. Supporting the parents in understanding the problem and supporting their efforts with the patient are very important.
Treatment of primary ADD/ADHD requires a multimodal approach. The mainstays are the understanding of the problem by parents, family, and teachers, behavioral modification, appropriate educational placement, and psychological support. Stimulant medication may also be used for certain patients but is not effective by itself and should only be used in addition to other services. Stimulant medication should never be viewed as a “magic pill.” Consultations with psychiatrists, psychologists, developmental pediatricians or other qualified consultants are often also helpful.

Learning Point
The differential diagnosis for attention problems includes:

• Normal Development
• Prematurity
• Developmental Disorders
  • Autism/Pervasive Developmental Disorder
  • Language Disorder
  • Learning Disabilities
  • Primary Attention Problems, i.e. ADHD, ADD
  • Sensory Deficit - hearing, vision
• Metabolic Disease
  • Iron Deficiency
  • Heavy Metals - lead
  • Hyperbilirubinemia
  • Medication Side Effects
• Congenital/Genetic/Neurological Disease
  • Congenital Infection
  • Fetal Alcohol Syndrome
  • Genetic Disorders, i.e. Fragile X, Turner Syndrome
  • Inborn Errors of Metabolism
  • Neurotrauma
  • Mental Retardation
  • Seizures, i.e. petite mal, temporal lobe
• Other
  • Boredom
  • Fatigue
  • Hunger
  • Hyperthyroidism
• Psychiatric Problems
  • Anxiety
  • Attachment Disorder
  • Bipolar Disorder
  • Conduct Disorder
  • Dissociative Disorder
  • Depression
  • Disruptive Behavior Disorder
  • Mood Disorder
  • Oppositional Defiant Disorder
  • Personality Disorder, i.e. aggression, antisocial behavior
  • Post-traumatic Stress Disorder
  • Psychosis, i.e. schizophrenia
  • Substance Abuse
  • Tourette Syndrome
• Social Problems
  • Abuse
  • Family Stress (including Attachment Disorder)
  • Normal communication problems - i.e. different languages, cultural and ethnic differences
  • Parenting, Ineffective
  • Poverty
  • Teaching, Ineffective

Questions for Further Discussion
1. What standardized parent and teacher questionnaires are available for evaluating attentional problems?
2. What types of behavior modifications are often recommended in educational settings for children with attentional problems?
3. What mental health professionals are available in your local community to help co-manage children with attentional problems?
4. What educational professionals are available in your local community to help co-manage children with attentional problems and learning problems?

Related Cases

Disease: Learning Disorders | Attention Deficit Disorder with Hyperactivity

Symptom/Presentation: Attention Deficit Disorder/ Overactivity | Behavior Problems

Specialty: Developmental Disabilities | General Pediatrics | Psychiatry and Psychology | School

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, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Learning Disorders and Attention Deficit Hyperactivity Disorder.

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

To view images related to this topic check Google Images.

Wender E. Hyperactivity in Behavioral and Developmental Pediatrics. Parker S and Zuckerman B. eds. Little Brown and Co. Boston, MA. 1995;185-94.

Borowsky, IW. Attention Deficit/Hyperactivity Disorder, in Pediatrics A Primary Care Approach. Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;404-407.

American Academy of Pediatrics. Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics. 2000;105(5):1158-1170.

Behavenet Clinical Capsule. Bellevue, WA.
Available from the Internet at http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm (rev. 2009, cited 12/7/2009).

Wilms Floet A, Scheiner C, Grossman L, Attention-Deficit/Hyperactivity Disorder. Pediatrics in Review. 2010;31:56-69

ACGME Competencies Highlighted by Case

Patient Presentation
A 3-month-old male was referred for a second opinion for chronic respiratory distress. The patient was a full-term infant who had transient tachypnea of the newborn and was monitored for 3 days without other interventions. His parents noted at about 3 weeks of age that his chest always seemed to “suck in.” At 6 weeks he was brought to his local physician who noted the “chest sucking” and told the family that he was having respiratory distress. He was given albuterol and oral steroids but the parents noted no changes with the treatment. They denied any color changes, difficulty feeding, pulling in at his neck, ribs or abdomen, splaying of the nasal alae, abnormal cries or other sounds. He did not have noisy breathing and it did not appear to bother him or change over time. His parents pointed out the “respiratory distress” while he was in the office. The family history was negative for any cardiac problems. There were “respiratory problems” in geriatric great uncles who were smokers.

The pertinent physical exam showed a smiling infant with a respiratory rate of 28, heart rate of 144, blood pressure of 80/40, temperature of 98.8° F., growth parameters in the 75-95% and his weight of 7.05 kg was tracking along the 90%. Oxygen saturation was 100% on room air taken pre-ductally. He had normal vocalizations when happy and when crying. While reclining in his mother’s lap, his abdomen was noted to be slightly more protuberant relative to his ribs. The lower sternum appeared to be more concave relative to the rest of the sternum and rib line. A tongue depressor placed horizontally across the ribs showed a concavity of 1.0 cm. The sternum and ribs were smooth without disruptions in the articulating surfaces. There was no head bobbing, nasal flaring, tracheal tugging, intercostal retractions or abdominal breathing. His HEENT examination, cardiac, abdominal and spine examinations were normal. The diagnosis of a mild pectus excavatum that was not causing respiratory distress was made. The parents were counseled that this was a common problem and that he only appeared to have his chest “sucking in” because his normal chest position was already concave and breathing accentuated the mild deformity. The natural history of the problem was discussed including that it possibly could become worse especially during times of accelerated skeletal growth such as puberty, but monitoring during regular health supervision visits was recommended.

Discussion
Pectus excavatum is a deformation of the chest wall where the sternum and ribs grow abnormally to form a concavity relative to normal positioning. Pectus carnitum is similar but forms a convexity. Pectus excavatum is much more common (90%) than pectus carnitum (7-8%) or other congenital chest wall deformities (2-3%). Pectus excavatum is usually noted at birth or in the first year of life. It may be relatively minor (the most common) or quite severe (rarer) with the concavity displacing internal organs and possibly causing pulmonary and/or cardiac abnormalities. Usually it is relatively stable, but may progress especially during times of rapid growth such as puberty. Thankfully most patients do not need treatment but severe pectus excavatum may cause psychological distress because of the chest wall appearance. Psychological distress, with or without pulmonary or cardiac abnormalities is an indication for treatment. Unfortunately surgical treatment is basically the only effective treatment available. Surgical techniques include open and closed procedures which involve basic elevation of the concavity through cartilage grafts or rodding.

Figure 79 -Axial image from a computed tomography exam of the chest without contrast shows depression of the sternum and a pectus excavatum deformity of the chest wall.

Learning Point
The most common signs of respiratory distress are increased respiratory rate and work of breathing. Tachycardia is common and as distress moves towards respiratory failure mental status changes are noted. Other signs of respiratory distress includes:

• Increased respiratory rate
• Nasal flaring
• Retractions - diaphragmatic, intercostal, subclavian, subcostal
• Abnormal sound production - grunting, stridor
• Difficulty speaking
• Skin changes - paleness or cyanosis (central or peripheral Note Bene: cyanosis is a late sign)
• Mental status changes - somnolence, head bobbing
• Poor muscle tone
• Cough and gag reflexes weak or absent
• Absent or decreased breath sounds
• Abnormal breath sounds - rhonchi
• Tidal volume changes
• Inspiratory-expiratory ratio changes

The differential diagnosis of respiratory distress includes:

• Normal variant
  • Periodic breathing
  • Pectus excavatum or carnitum
• Head and Neck
  • Choanal stenosis and atresia
  • Mass - congenital cysts, tumor
  • Small midface and/or enlarged structures relative to each other
    • Enlarged tonsils and adenoids
    • Enlarged tongue
• Pulmonary
  • Asthma
  • Aspiration, chronic
  • Cystic fibrosis
  • Diaphragmatic hernia
  • Lobar emphysema
  • Tracheolayngomalacia
  • Subglottic stenosis
• Cardiac
  • Cyanotic congenital heart disease
  • Non-cyanotic congenital heart disease - Vascular rings
• Central Nervous System
  • Neuromuscular disease - Guillian-Barre syndrome, spinal cord injury
  • Seizures
• Infection
  • General infection causing fever
  • Abscess - peritonsillar, retropharyngeal, pleural effusion
  • Bronchiolitis
  • Tracheolayngobronchitis
  • Epiglottitis
  • Infantile botulism
  • Pertussis
  • Pneumonia
  • Sepsis
• Metabolic
  • Metabolic acidosis - diarrhea and dehydration
  • Drugs and toxins- salicylates
  • Diabetic ketoacidosis
  • Inborn errors of metabolism
• Trauma
  • Penetrating - pneumothorax
  • Non-penetrating - crush, burn
  • Child maltreatment - smothering, choking
  • Foreign body
  • Near drowning
  • Smoke inhalation

Questions for Further Discussion
1. What are indications/criteria for respiratory failure?
2. What treatment should be given for respiratory failure?

Related Cases

Disease: Pectus Excavatum | Cartilage Disorders

Symptom/Presentation:Respiratory Distress

Specialty: Allergy / Pulmonary Diseases | General Pediatrics | Surgery | Radiology / Nuclear Medicine / Radiation Oncology

Age: Infant

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, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Cartilage Disorders.

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

To view images related to this topic check Google Images.

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:228-232.

Seidel JS. Respiratory Distress in Pediatrics a Primary Care Approach. Berkowitz CD, ed.. W.B. Saunders Co. Philadelphia, PA. 1996;135..

Hebra A. Pectus Excavatum. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1004953-overview (rev. 9/21/09, cited 12/16/09).

ACGME Competencies Highlighted by Case

Patient Presentation

A 15-year-old female came to the emergency room with lower abdominal pain for 1 week. The pain was described as constant mild pain with episodes of worsening. She stated she had increased urinary frequency but no urgency, change in urine color or smell. She had normal stooling. The patient had her normal period 2 weeks ago and was sexually active without consistent use of any contraceptive method including condoms. She stated that she had a vaginal discharge but could not describe it further. She was also having some back pain. She had had no fever, chills, rash, and had been eating well. The past medical history was positive for a previous episode of pelvic inflammatory disease caused by Chlamydia several months previous that was diagnosed by cervical cultures and treated as an outpatient. Social history revealed tobacco smoking and beer drinking but no other alcohol or drugs. She denied any violence or being involved with the police. She was taking an anti-depressant.

The pertinent physical exam showed an alert female in no distress with normal vital signs and growth parameters. Abdominal examination showed lower abdominal/suprapubic diffuse tenderness without radiation with no guarding. There was no flank tenderness or pain reproduction with palpation of the back. Her genitourinary examination showed a normal introitus. She had a nulliparous appearing cervix with yellowish discharge from it. Bimanual examination revealed cervical motion tenderness without adnexal fullness or masses. The uterus was anteverted and normal size. The rest of her examination was normal. The work-up included a normal urinalysis and a negative pregnancy test. Urinary screening test for Chlamydia trachomatis was positive as was a cervical culture later on. Urine screening and cervical cultures for Neisseria gonorrhea were negative. The diagnosis of recurrent pelvic inflammatory disease was made. The patient was treated with azithromycin, ceftriaxone in the emergency room and also to continued to take the doxycycline she was already taking for acne. The patient’s mother was very concerned about her daughter but refused human immunodeficiency virus screening as this had previously been done. The mother wanted to followup with a regularly scheduled appointment in 2 days with her daughter’s adolescent medicine specialist. The mother assured the emergency room physician that ongoing gynecological, psychological and social care was being obtained for her daughter, and appointments in the electronic medical record system supported the mother.

Discussion
Pelvic inflammatory disease (PID) is an inflammatory disease of the uterus, fallopian tubes and adjacent pelvic structures caused by ascending microorganisms from the vagina and cervix particularly Neisseria gonorrhea and Chlamydia trachomatis. Increased risks for PID includes early age at first intercourse, multiple sexual partners, intrauterine device insertion and tobacco smoking. Approximately 11% of reproductive age women are affected. PID increases the risk of dyspareunia, chronic pelvic pain, pyosalpinx, tubo- ovarian abscess, pelvic adhesions, ectopic pregnancy, and infertility. The overall complication rate is ~15-20% and these often require surgical treatment.

Learning Point
After 1 episode of PID, about 12% of women will be infertile. After a second episode this rises to ~25% and after a 3rd episode this increases to ~50%. Overall there is a doubling of the risk of infertility after each episode.

The PEACH (Pelvic Inflammatory Disease Evaluation and Clinical Health) study which evaluated outpatient versus inpatient treatment for PID found a rate of ~18% infertility with a mean long-term followup of 35 months. This study included patients 14-37 years but without subgroup analysis of adolescents. In another study, these researchers found that barrier methods (especially male condoms) significantly helped to prevent chronic pelvic pain, recurrent PID, and infertility.

Questions for Further Discussion
1. What are the recommended treatment options for PID?
2. What are the recommendations for treating partners of patients with known PID and how are the partners contacted locally?
3. What are the legal requirements for treating minors with sexually transmitted infections?

Related Cases

Disease: Pelvic Inflammatory Disease | Chlamydia Infections

Symptom/Presentation: Abdominal Pain | Pelvic Pain | Vaginal Discharge

Specialty: Adolescent Medicine | Emergency Medicine | Infectious Diseases | Obstetrics / Gynecology

Age: Teenager

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, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Pelvic Inflammatory Disease, Chlamydia Infections, and GonorrheaTo view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002 May;186(5):929-37.

Ness RB, Randall H, Richter HE, Peipert JF, Montagno A, Soper DE, Sweet RL, Nelson DB, Schubeck D, Hendrix SL, Bass DC, Kip KE. Pelvic Inflammatory Disease Evaluation and Clinical Health Study Investigators. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health. 2004 Aug;94(8):1327-9.

Lareau SM, Beigi RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am. 2008 Dec;22(4):693-708, vii.

Hills JB, Lockrow E. Pelvic Inflammatory Disease. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/256448-overview (rev. 8/27/2009, cited 11/30/09).

ACGME Competencies Highlighted by Case