Month: December 2004

What Causes Recurrent Abdominal Pain?

Patient Presentation
A 7-year-old male comes to clinic with a 3 month history of abdominal pain that occurs off and on. The pain is periumbilical, lasts several minutes and then resolves. He says it “feels like someone is twisting me.” The episodes usually occur daily and sometimes several times per day. The pain does not wake him at night, but he wants to sit down when the pain occurs.
The past medical history shows that he has a normal diet and is otherwise well.
The review of systems shows he has been having harder bowel movements for the past few months with occasional painful defecation. His bowel movements are every 2-4 days and occasionally clog the toilet. The rest of his review of symptoms is negative including urinary problems.
The pertinent physical exam shows that his growth parameters are normal. His abdominal examination shows a soft, non-tender abdomen with no organomegaly and normal bowel sounds. He has stool palpable in the left lower and upper quadrants. His rectal examination shows normal tone and soft stool in the rectal vault. The rest of his genitourinary, neurological, and orthopaedic examinations are normal.
The abdominal flat plate radiograph showed stool throughout the abdomen.
The diagnosis of constipation was made. The patient was placed on a bowel clean-out program with enemas, and then started on a maintenance program with MiraLaxTM stool softener. He was also given information on how to use a toilet sitting program and increase the fiber in his diet.

Figure 6 – 12-27-04 – AP radiograph showing the colon to be filled with stool from the cecum to the rectum.

Discussion
Recurrent abdominal pain is defined as attacks of abdominal pain that recur over at least 3 months in children between 4-14 years old. Acute problems like appendicitis are rarely the cause. Many children are healthy and growing with no abnormalities on physical examination or laboratory work-up.
Laboratory and/or radiological evaluations should guided by the history and physical examination and should be used, especially if there is evidence of infection, inflammation, or anatomic abnormality suspected. Usually simple tests such as a complete blood count, erythrocyte sedimentation rate, liver tests and urinalysis are all that are needed. Radiographic evaluation usually starts with a plain abdominal radiograph but may also include fluoroscopy, ultrasound, or CT scan.
Recurrent abdominal pain usually has a more ominious etiology if the following signs are present:

  • Emesis
  • Fever
  • Awakening from sleep
  • Weight loss
  • Pain that is not periumbilical
  • Blood in stool or emesis
  • Bilious emesis
  • Abnormal laboratory tests

Functional abdominal pain is caused by motility problems. Discomfort can result from contractions that can be intense and poorly coordinated and thereby be perceived as painful, especially if there is elevated sensitivity or anxiety. Functional abdominal pain often is intermittant, colicky pain not associated with meals or bowel movements. Constipation is the exception as it is is often worse after eating and better after bowel movements. Functional abdominal pain is ‘real’ pain and is not psychosomatic.
Typical features of functional abdominal pain include periumbilical location, a crampy or colicky nature, pallor during attacks, not awakening at night, missing school or other activities, a family history of abdominal pain, a high-anxiety personality and lack of ominious signs on physical examination or history.

Constipation
A normal bowel pattern is thought to be a sign of good health. Constipation generally is defined as infrequent or painful defecation. Constipation can be very disturbing to the patient and family.

Most children develop constipation after the child begins to associate pain (e.g. a hard bowel movement) with defecation. The child then begins to withhold the stools trying to decrease the defecation discomfort. As stool withholding continues, the rectum dilates and gradually accommodates with the normal defecation urge disappearing. Passing large hard stools infrequently reinforces the defecation pain. The cycle continues. If the cycling is severe enough, worsening stool retention and more abnormal defecation dynamics occurs. Chronic rectal distension results in both loss of rectal sensitivity, and loss of urge to defecate, which can lead to encopresis.

Treatment mainstays are:

  • Evacuate the colon – a clean out by enemas or oral medication
  • Stop painful defecation – by using laxatives in a maintenance regimen so patients have a soft stool daily
  • Establish regular bowel habits – through toilet sitting

A balanced diet is important. Increasing dietary fiber may also help.
Medications for constipation include osmotic laxatives, stimulant laxatives, stool softeners and lubricants. MiraLax is polyethylene glycol and is an osmotic laxative. It is usually used as a maintenance medication in a dose of 0.5 -1 gram/kg/day divided BID. The dose can be titrated to have one soft stool per day.

Learning Point
A differential diagnosis of recurrent abdominal pain includes the following:

  • Gastrointestinal
    • Constipation
    • Crohn’s disease
    • Gastroesophageal reflux
    • Food sensitivity or intolerance – lactose intolerance
    • Malrotation
    • Pancreatitis – chronic, relapsing
    • Peptic ulcer
  • Genital
    • Endometriosis
    • Inguinal hernia
    • Ovarian torsion
    • Pregnancy
    • Testicular torsion
    • Sexually transmitted infection – pelvic inflammatory disease
  • Hematologic/Oncologic
    • Sickle cell anemia
    • Tumor
  • Neurologic / Psychologic
    • Abdominal epilepsy
    • Abdominal migraine
    • Abuse
    • Psychological stress
  • Renal
    • Hydronephrosis
    • Renal stones
    • Urinary tract infection
  • Miscellaneous
    • Lead poisoning
    • Parasites
    • Hereditary angioedema

Questions for Further Discussion
1. When should a patient be referred to a gastroenterologist for recurrent abdominal pain?
2. What other options than enemas are available to clean out the constipated bowel?
3. How should functional abdominal pain be evaluated and treated?

Related Cases

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

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Chronic Abdominal Pain

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:117-122.

Gunn VL, Nechyba C. The Harriet Lane Handbook. 16th. Edit. Mosby Publications: St. Louis. 2002:811-812.

Woodhead JC. Pediatric Clerkship Guide. Mosby., St. Louis MO, 2003:121-130.

Borowitz S. Constipation. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic471.htm (rev. 7/14/04, cited 12/6/04).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
December 27, 2004

What Treatments Should Be Used for Influenza?

Patient Presentation

A 13-month-old previously healthy female comes to clinic with a 1 day history of non-productive cough, runny nose, fever to 102 degree F and being fussy. She has been drinking well but not eating.
Her social history reveals that she attends day care where influenza A has been documented. His father has had similar symptoms for 3 days.
The review of systems reveals no rashes, nausea, emesis, change in urination or defecation. She has not received an influenza vaccine.
The pertinent physical exam shows her to have a respiratory rate of 18 and is well hydrated. HEENT reveals copious clear rhinorrhea, teary eyes but conjunctiva are clear, ears, throat and neck are normal. Her lung examination has transmitted course upper airway sounds but no rubs, rales or rhonchi. The remainder of her examination is normal.
A clinical diagnosis of influenza was made based upon consistent symptoms and known contacts.
Laboratory testing was not done because of known contacts.
She was treated with Oseltamivir for 5 days and supportive care. She began improving after day 3. Her father was not treated because he has had symptoms for more than 2 days, but the other household contacts were given prophylaxis with Amantadine.

Discussion
Influenza is an orthomyxovirus first isolated in 1933. There are 3 types:

  • A – moderate to severe disease in every age group
  • B – milder epidemic, primarily affects children
  • C – rarely reported in humans

New variants results from antigenic change called antigenic drift. Rates of infection are highest in children (10-40%) but most serious illness and death occurs in people >65 years or persons of any age with medical conditions that put them at risk for infection.
Deaths do occur in children but are not common.
Incubation period is 1-3 days with an average of 2 days. Children can be infectious for >10 days.

High risk children include those with:

  • Asthma or other chronic pulmonary disease
  • Hemodynamically significant cardiac disease
  • Immunosuppressive disorders or therapy
  • HIV
  • Sickle cell anemia and other hemoglobinopathies
  • Diseases requiring long term salicylate therapy such as rheumatoid arthritis or Kawasaki disease
  • Chronic renal problems
  • Chronic metabolic diseases
  • Children under 24 months of age

Influenza is characterized by the abrupt onset of respiratory signs and symptoms (i.e. nonproductive cough, sore throat, rhinitis) accompanied by constitutional symptoms (i.e. fever, malaise, headache, myalgia). In children, otitis media, nausea and vomiting are common.
Symptoms usually resolve over a few days for most people, but cough and malaise can last >2 weeks.

Rapid diagnostic testing is approximately 70% sensitive for detecting influenza and approximately 90% specific compared with the gold standard of viral culture. Therefore if the test is positive, the result is most likely correct. If the test is negative, as many as 30% of the negative results are falsely negative. Tests are most reliable when there is known influenza in the community. Once influenza is documented in the community or geographical area, a clinical diagnosis can be made for patients with consistent signs and symptoms, especially during peak activity.
Prevention includes vaccination for high risk groups, meticulous hand-washing, use of tissue to cover noses and mouths during coughing or sneezing, and self-imposed quarantine to keep infected individuals away from other persons.

Learning Point
There are currently four medications available to treat influenza (i.e. Amantadine, Rimantadine, Oseltamivir, Zanamivir ). All are similarly effective in reducing symptom duration by 1-2 days, if given within the first 2 days of the onset of symptoms.
Three medications can be given for influenza prophylaxis (i.e. Amantadine, Rimantadine, Oseltamivir). The dosing recommendations depend on the child’s age and the indication for use (i.e. treatment or prophylaxis). Which medication to use may also be dictated by local medication supplies and cost.

The Centers for Disease Control currently recommends that:
Patients with high risk medical conditions should be given priority for antiviral therapy

For treatment
Use Oseltamirvir or Zanamivir (if available)
Patients with potentially life-threatening influenza-related illness should be treated
Patients with high risk medical conditions in the first two days of symptoms should be treated

For prophylaxis
Use Amantadine or Rimantadine (if available)
Persons who live or work in institutions should be given prophylaxis if an institutional outbreak occurs
Patients with high risk medical conditions should be given prophylaxis if they are likely to be exposed to others infected with influenza (e.g. household contacts)

Figure 5 – 12-20-04 – Table of Recommended daily dosage of influenza antiviral medications for treatment and prophylaxis from the CDC Morbidity and Mortality Weekly Report 28 May 2004 at http://www.cdc.gov/mmwr/PDF/rr/rr5306.pdf

Questions for Further Discussion
1. What are the current guidelines for giving influenza vaccine?
2. How effective are alcohol-based handwashes for decreasing infection?

Related Cases

To Learn More

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

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Influenza (Flu)

American Academy of Pediatrics. Influenza, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;382-391.

Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP) (MMWR 28 May 2004;53[RR06]:1-40)

Centers for Disease Control. Influenza. Available from the Internet at http://www.cdc.gov/flu/ (cited 11/29/04).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
December 20, 2004

What Causes Generalized Eyelid Swelling?

Patient Presentation
A 3-year-old male comes to clinic with complaints of 2 weeks of intermittent eye swelling. The mother describes that there is slight puffiness in the lower outer corners of both eyes intermittently and that the father has also noted this. It was noticed ~5 times during the 2 weeks. There is not a time of day when it appears to occur more often. It lasts for an unknown period of time. There has been no swelling of the extremities, difficulties in putting on shoes or clothes, and no swelling of the hands or feet.
The past medical history is positive for urticaria of unknown cause several months previous.
The family history is negative for heart, kidney, liver, or oncological disease. There was hearing loss in an elderly relative.
His social history reveals that he began child care ~1 month ago.
The review of systems is negative for recent illnesses, allergic symptoms, itching, eating well with no weight loss, fevers, night sweats/chills, urinary or gastrointestinal changes, skin changes, neurological symptoms, decreased activity, and excessive bruising or bleeding.
The pertinent physical exam reveals he is well appearing with normal growth and vital signs. He has no eye or facial swelling. There is no redness or skin discoloration of eyes or face. He has no tenderness to palpation of his facial bones or eyes. The rest of his ophthalmologic exam is normal. His nose has a small amount of clear rhinorrhea. There is no boggy or discolored nasal mucosa. He has shoddy anterior cervical lymph nodes. His heart, pulmonary, and abdominal examination are normal. He has no edema of his hands, feet or scrotum. He has a few small bruises over the anterior shins. His neurological examination is normal.
The laboratory evaluation included a normal BUN, creatinine and urinalysis.
As this child’s history, physical examination and brief laboratory evaluation appear to be normal at the present time
a diagnosis of intermittent eye swelling of unknown etiology was made. The family was instructed to monitor the patient, keep a symptom diary and return if the problem persists or changes. At follow-up the patient had no further problems.

Discussion

Children often present with complaints whose etiology cannot be determined at that time and watchful waiting is an appropriate course of action. Careful history and physical examination should be performed trying to exclude any serious current problem. Judicious use of laboratory testing can be helpful to include or exclude serious problems. Laboratory testing can also sometimes be helpful by providing a baseline test for future reference. Parents can be sent home with instructions to watch their child closely and report any further progression of the current complaint or additional problems. Symptom diaries often are helpful as data can be collected prospectively and then possible patterns discerned from the records. Parent should be told what symptoms to report immediately. They should also be told a general time period that the complaint probably should be resolved by or the patient should then be seen again.

Learning Point
The differential diagnosis of generalized eye swelling includes:

  • Allergies – seasonal allergic rhinitis, urticaria, angioedema
  • Heart disease
  • Infection – localized infection such as preseptal or orbital cellulitis, generalized sepsis
  • Liver disease
  • Malnutrition – food faddism, malabsorption
  • Oncologic disease – primary tumor or metastatic disease
  • Ophthalmologic disease – trauma, conjunctivitis or blepharitis with rubbing
  • Renal disease – renal failure, nephrotic syndrome

In children, rubbing of the eyes caused by allergies or URIs are common. Also nephrotic syndrome can present with mild periorbital edema. Chalazion and hordeolums usually cause localized swelling. Eyelid tumors such as nevi, dermoid cysts and capillary hemangioma may be localized or more generalized.

Questions for Further Discussion
1. Where is generalized body edema likely to be detected on physical examination?
2. What work-up should be considered if heart, renal or liver disease is suspected?

Related Cases

To Learn More

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

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Eyelid and Tear Gland Problems.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2362-2366.

Woodhead JC. Pediatric Clerkship Guide. Mosby., St. Louis MO, 2003:241-244.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
December 13, 2004

What are Presentations for Rickets?

A 14 month-old Africian American male comes to clinic for poor weight and height gain. He was a full-term infant with weight and height in the 90%, and head circumference at the 50% until 9 months of age when he began to lose weight and height and cross percentiles on the growth charts.

The past medical history revealed that he was exclusively breastfed until 6 months of age with some infant formula since. He takes little baby food of a limited variety. He is a picky eater and refuses cow’s milk and bread products. He eats fruits, vegetables or meat. He refuses vitamin supplements. His mother eats a regular balanced diet.
The review of systems is negative including no abnormal stooling or urination.
His past family history is normal.
His pertinent physical exam shows his vital signs are normal. His weight and height were at the 3% while his head was at the 50%. He was described as clingy and fearful. Head shows slight frontal bossing. Rib cage has mild palpable swelling at the costovertebral junctions. His abdomen is protuberant with normal bowel sounds and no organomegaly. His extremeties have widened wrists and ankles. There is no bowing of his lower extremeties, but he has a trundling gait. He has no peripheral edema. His neurological examination is normal with good tone.
The patient was admitted for evaluation and initiation of treatment.
The laboratory evaluation included: calcium was low at 6.5 mg/dl (normal = 8.8-10.6), phosphorus was low at 3.0 mg/dl (normal = 3.8-6.2), and alkaline phosphatase was high at 1917 U/l (normal = 104-345). Vitamin D 25-OH was low normal at 12.0 ng/ml (normal = 10-68) and Vitamin D 1,25-OH was high at 87 pg/ml (normal = 15-75), parathyroid hormone was high at 470 pg/ml (normal = 10-65). Other laboratory evaluations including urine calcium and phosphorus were normal.
The diagnosis of vitamin D deficiency rickets was made.
The patient’s clinical course included treatment with calcium, calcitrol, and intensive nutritional and behavioral therapy which was continued as an outpatient.

Figure 3 – 12-06-04 – AP radiograph of the chest showing promient costochondral joints bilaterally – a “Rachitic Rosary.”

Figure 4 – 12-06-04 – AP and lateral radiographs of the left wrist shows in the distal radius and ulna metaphyseal splaying and partial loss of the zone of provisional calcification bilaterally. The right wrist had a similar appearance.

Discussion
When the osteoid cells in bones fail to calcify in a growing person this is termed Rickets. If this occurs in an adult it is called osteomalacia.

Ultraviolet light in the skin changes cholesterol to Vitamin D3 (i.e. cholecalciferol). Vitamin D3 then is hydroxylated in the liver to make Vitamin D 25-OH (i.e. calcidiol, the circulating reserve metabolite). It then undergoes hydroxylation again in the kidney to Vitamin D 1,25-OH (i.e. calcitriol, the active metabolite).

Vitamin D 1,25-OH helps calcium and phosphorous absorption from the intestine, increases kidney reabsorption of phosphorus, and it causes calcium and phosphorus to be released from the bone. Increasing the concentrations of calcium and phosphorus in extracellular fluid causes osteoid cells to calcify. Parathyroid hormone increases the 1-hydroxylation step of vitamin D metabolism and thereby helps regulate calcium metabolism.

Therefore if Vitamin D 1,25-OH is low, hypocalcemia develops, causing parathyroid hormone to be excessively released. This produces loss of phosphorus by the kidney and more difficulties with calcium homeostasis. The parathyroid hormone causes the calcium extracellular concentration to return to normal but with a low phosphorus level. This causes osteoblasts to reabsorb bone so phosphorus metabolism is normalized. Alkaline phosphatase produced by ostoblast cells also leaks to the extracellular fluids causing elevation of its level. Therefore most children with rickets, have a normal to low calcium, low phosphorus, high parathyroid hormone and high alkaline phosphatase levels. Vitamin D 25-OH is usually low with Vitamin D 1,25-OH being low, normal, or high.

Severe rickets in the US is rare but there are high-risk populations such as infants who are exclusively breast-fed without supplementation of Vitamin D (because there is little Vitamin D in breast-milk), dark-skinned individuals (because of decreased conversion of the steroid into the skin), and people with little sun exposure such as those in northern climates, excessive smog exposure, or living in institutions.

Commercially produced milk and infant formulas are fortified with Vitamin D. Infants and children should receive between 200-400 IU daily.

The best treatment is prevention but if rickets occurs adminsistration of vitamin D and calcium for several weeks is needed. Hypocalcemia caused by remineralization of the bone matrix is a potential side effect of treatment called hungry bone syndrome.

Learning Point
Clinical and radiographic presentations of rickets include:

  • General
    • Generalized malnutrition and lack of normal physiologic growth
    • Anorexia
    • Generalized hypotonia – cause unknown
    • Tetany – caused by hypocalcemia, may be precipitated by infection
  • Skeletal
    • Craniotabes – especially along the suture line
    • Skull thickening – particularly frontal area with delayed closure of anterior fontanelle
    • Rachitic Rosary – prominance of the costochondral junctions of the ribs
    • Harrison’s groove – flaring of the ribs over the diaphragm caused by muscles pulling on weak bones
    • Pectus carinatum – caused by muscles pulling on weak bones
    • Kyphoscoliosis
    • Widened wrists and ankles – knobby deformity of epiphysis caused by metaphyseal splaying
    • Genu varum or genu valgum
    • Fractures – especially greenstick fractures

Questions for Further Discussion
1. What other nutritional deficiencies should be looked for?
2. How could rickets and malnutrition have been prevented?

Related Cases

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

Gunn VL, Nechyba C. The Harriet Lane Handbook. 16th. Edit. Mosby Publications: St. Louis. 2002:460.

Fineberg L. Rickets. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2014.htm (rev. 12/10/03, cited 11/18/04).

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2156-2160.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
December 6, 2004