Patient Presentation
An 11-month-old female was transferred because of an increasing pleural effusion. She had upper respiratory tract infection symptoms for 2 days and then began to have increased cough, deep breathing and a fever to 103.6° F. A chest x-ray showed left lower lobe pneumonia and a small pleural effusion. She was begun on oxygen, clindamycin and ceftriaxone, but continued to have respiratory distress. Another radiograph showed an increasing pleural effusion and vancomycin was begun along with azithromycin. Clindamycin was discontinued. Another radiograph showed increased pleural effusion, so she was transferred to the regional children’s hospital on day 2-3 of admission. The past medical history showed recurrent otitis media with placement of bilateral pressure equalizing tubes. The family history and review of symptoms were negative.

The pertinent physical exam showed an infant with a respiratory rate of 46 breaths/minute and a temperature of 40.1° C on 3 liters nasal canula. HEENT examination showed clear rhinorrhea and mild tracheal tugging. Chest examination showed decreased breath sounds at the left base and up approximately 50% of the chest. There were dull sounds to percussion in the same area. Mild end expiratory sounds were heard that stopped after coughing in the left lung. There were mild intercostal retractions. The rest of the examination was negative. The laboratory evaluation at the outside hospital showed a C-reactive protein of 10.4 mg/dl, and a white blood cell count of 11.8 x 1000/mm² with 50% polymorphonuclear cells and 10% left shift. Blood cultures were eventually negative. The diagnosis of left lower lobe pneumonia with pleural effusion was confirmed. The radiologic evaluation of a computed tomography of the chest on day 3-4 showed a pneumonia and non-loculated pleural effusion. The patient’s clinical course showed that she continued on her antibiotics and on day 3-4 had decreased fever, decreased oxygen requirement and improvement of her respiratory distress. Vancomycin was discontinued and the patient was discharged on day 5-6, after a chest radiograph showed stabilization of the effusion. She received a total of 10 days of ceftriaxone and 5 days of azithromycin. At followup 8 weeks later, her chest radiograph was normal.

Figure 82 – PA and left lateral decubitus radiographs of the chest demonstrate a moderate-sized free flowing left pleural effusion and associated left lower lobe airspace disease.

Figure 83 – CT scan of the chest performed with intravenous contrast shows a left-sided pleural effusion on soft tissue windows (above) and associated left lower lobe pneumonia on lung windows (below). There is no enhancement of the pleura to suggest emphyema and no lung abscess was seen.

Discussion
Pneumonia is an inflammation of the lung parynchema with consolidation of the tissue and filling of the alveolar air space with exudate, fibrin and inflammatory cells. It is the most common cause of pediatric death in the world and is described as the “forgotten killer of children” by UNICEF and the WHO. This is particularly true in developing countries. But while the United States and other developed countries see fewer deaths and morbidity related to pneumonia, complications of pneumonia still occur.

The most common organisms causing outpatient pneumonias in the U.S. are: Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Streptococcus pneumoniae, and a variety of respiratory viruses. Vaccines to combat pneumonia are available and include: Haemophilus influenza B, influenza, measles, pertussis, and varicella. Use of respiratory syncytial virus immunoglobulin in certain premature infants to prevent RSV pneumonia and its complications is also considered standard of care in the U.S..

Learning Point
Complications of pneumonia include:

• Pulmonary functioning
  • Respiratory distress
  • Pulmonary failure including adult respiratory distress syndrome
  • Death
  • Acute asthma exacerbation
• Primarily pulmonary parenchyma
  • Necrotizing pneumonitis
  • Pulmonary abscess
  • Pneumatocoele
  • Lung cavitation, fibrosis, and bronchiolitis obliterans
  • Granuloma formation
• Primarily pleural space
  • Pleural effusion with or without loculations
  • Empyema
  • Pneumothoraces
  • Tension pneumothorax with diminished cardiac output
• Infectious disease
  • Bacteremia and sepsis
  • Secondary bacterial pneumonia after primary viral pneumonia
• Other
  • Hilar adenopathy with compression
  • Need for imaging procedures – ultrasound, chest tomography
  • Need for surgical procedures – chest tube, thoracotomy, pleural decortication
  • Pain
  • Pregnancy related complications including increased maternal death and premature birth

Questions for Further Discussion
1. What are some risk factors for increased pneumonia complications?
2. What are indications for inpatient and/or surgical treatment of pneumonia?
3. What is the epidemiology of seasonal influenza and novel Influenza A, H1N1 in my own location?

Related Cases

Disease: Pneumonia

Symptom/Presentation: Cough | Respiratory Distress | Shortness of Breath

Specialty: Allergy / Pulmonary Diseases | Infectious Diseases | 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: Pneumonia and at Pediatric Common Questions, Quick Answers for this topic: Pneumonia

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

To view images related to this topic check Google Images.

Tan TQ, Mason EO Jr, Wald ER, Barson WJ, Schutze GE, Bradley JS, Givner LB, Yogev R, Kim KS, Kaplan SL. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. Pediatrics. 2002 Jul;110:1-6.

Madhi SA, Levine OS, Hajjeh R, Mansoor OD, Cherian T. Vaccines to prevent pneumonia and improve child survival. Bull World Health Organ. 2008 May;86(5):365-72.

Kamangar N, Rager C, Sharma S. Pneumonia, Bacterial. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/300157-overview (rev. 8/21/2009, cited 5/12/10).

Bennett JN, Domachowske J. Pneumonia. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/967822-overview (rev. 2/26/2010, cited 5/12/2010).

ACGME Competencies Highlighted by Case

Patient Presentation
A 6-year-old female came to clinic for a preoperative evaluation for a multiple caries dental procedure. She was in her normal state of health. The past medical history revealed hypoplastic left heart syndrome (HLHS) treated with tricuspid valvoplasty, coarctation of the aorta repair, a bi-directional Glenn procedure and later a Fontan procedure. She had received her well-child care and despite multiple surgical complications of the procedures she was attending kindergarten and making good academic progress.

The pertinent physical exam showed an alert patient with growth parameters in the 40-75% for age. Blood pressure and pulse were also normal. HEENT revealed multiple caries and pressure-equalizing tubes in both ears. The chest showed multiple well-healed scars mainly centrally but also previous chest tube scars laterally. Heart showed a Grade III almost continuous murmur over the anterior upper part of the chest without a thrill. The murmur could be heard laterally and in the back but not to the axilla nor radiating to the neck. The rest of the examination was normal.

The diagnosis of multiple caries and HLHS status post multiple procedures was made. The patient had an appointment scheduled with her cardiologist and the anesthesiologist for that afternoon. The dental resident also seeing the patient was not sure what HLHS and a Norwood procedure were. The pediatrician described the general idea of using the right ventricle as the main pump for the systemic circulation, and needing to balance the pressures and flows to the pulmonary and systemic circulations preferably without mixing of the circulations. She also described how over the course of her practice the treatment of patients with HLHS had moved from being almost universally fatal, to using heart transplantation and then having more success with palliative surgical procedures. She noted that despite the improvements in potential treatment, many patients still die in infancy and in early life, because of the disease itself or the numerous complications.

Discussion

Some main surgical procedures for congenital heart disease include:

• Atrial Septostomy
  • Used to increase mixing of blood at the atrial level such as transposition of the great arteries, tricuspid atresia and mitral atresia
  • Shunt: Balloon-tipped catheter creates a larger hole in the atria
• Blalock-Taussig Shunt
  • Used for low pulmonary flow states such as Tetrology of Fallot, HLHS, tricuspid atresia
  • Uses systemic arterial flow to increase pulmonary flow
  • Regular Shunt: Subclavian artery to pulmonary artery by direct anastomosis or by graft
• Glenn Shunt
  • Used often as intermediate step to a Fontan procedure, especially in infancy and toddlerhood
  • Uses some systemic venous return to increase pulmonary flow
  • Shunt: Superior vena cava to right pulmonary artery by graft

Patient Presentation
An 8-year-old male came to clinic for a second opinion of an elevated serum alkaline phosphatase level. He originally went to an emergency room for abdominal pain (diagnosed with constipation) and had laboratory testing that showed an isolated alkaline phosphatase of 2442 U/L (nl 70-325 U/L). An initial workup completed by his private physician included a liver and gallbladder ultrasound, esophagogastroduodenoscopy and colonoscopy which were negative. Four weeks later he had another alkaline phosphatase that was 2378 U/L and was referred for a second opinion. He has a history of constipation that improves with fiber and Miralax®. He has been growing well and has had no fevers, chills, sweats, nausea, emesis, diarrhea, rashes, cough, pain or difficulty sleeping. The family history is positive for diabetes, stroke and constipation. There is no other history of gastrointestinal disease including liver or gallbladder nor bone disease. The review of systems was extensively reviewed and was negative.

The pertinent physical exam showed a healthy appearing male with a growth parameters that were 25-50% except for weight which was 10% and was consistent with previous measurements. The abdominal and skeletal examinations were negative. The laboratory evaluation currently 5 weeks after the second testing included tests for rickets, endocrinopathies, kidney disease and malignancies and was negative. The alkaline phosphatase was 184 U/L at this time, and isoenzymes were not performed. The diagnosis of probable benign transient hyperphosphatasemia of childhood was made although this child was older than 5 years, and for this reason another level was suggested to be checked again in 4 weeks with the primary care physician. As this is a benign disease no other specific treatment was recommended.

Discussion
Alkaline Phosphatase (AlkPhos) is found mainly in the bone and liver but also in the intestine, kidney, placenta, lung, neutrophils, lymphocytes, and endothelium. The levels are significantly increased over normal adult levels during childhood and adolescence. They increase during puberty, during pregnancy and increase again slightly in older people. They can also be increased after liver and biliary surgeries. There are some differences between boys and girls with boys having a slightly higher AlkPhos than girls.

Benign hyperphosphastemia of infancy and childhood is a benign disease with an unknown etiology. It is often found incidentally during routine blood analysis. It is most common in children but has been reported in adults. Diagnostic criteria include:

• < 5 years of age in the absence of symptoms or presence of an unrelated illness such as seizures
• No evidence of bone or liver disease clinically or biochemically
• Isoenzyme analysis with an elevation in both bone and liver fraction
• AlkPhos increased 3-50 times normal range for age
• AlkPhos returns to normal level within 4 months

Learning Point
The differential diagnosis of an elevated AlkPhos includes:

• Normal/Factitious – patient is a child but is compared to adult norms
• Bone
  • Healing fracture
  • Osteomalacia
  • Rickets
• Liver
  • Cholestasis
  • Intrinsic liver disease
  • Malignancy with liver metastases
• Malignancies
  • Gynecologic
  • Primary liver
  • Primary bone
  • Metastasis, particularly to liver
• Other
  • Benign transient hyperphosphatasemia
  • Bowel perforation
  • Congestive heart failure
  • Infectious – cytomegalovirus, Epstein-Barr virus
  • Infarction (especially in healing phase) – bowel, kidney, lung, myocardium, pancreas, spleen
  • Malabsorption
  • Pancreatitis
  • Pregnancy
  • Renal disease
  • Sarcoidosis
  • Secondary hyperparathyroidism
  • Sepsis
  • Surgery – liver, biliary
  • Ulcerative colitis

Questions for Further Discussion
1. What would be indications for a gastrointestinal consultation?
2. What other symptoms might suggest a skeletal abnormality?

Related Cases

Disease: Benign Transient Hyperphosphatasemia of Childhood | Bile Duct Diseases | Bone Diseases

Symptom/Presentation: Abnormal Laboratory Test

Specialty: Gastroenterology | General Pediatrics | Oncology | Orthopaedic Surgery and Sports Medicine

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: Bile Duct Diseases and Bone Diseases.

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

To view images related to this topic check Google Images.

Bakerman S, Bakerman P, Strausbauch P. Bakerman’s ABC’s of Interpretive Laboratory Data. 4th edit. Interpretive Laboratory Data Inc. Scottsdale, AZ. 2000:33-35.

Tolaymat N, de Melo MC. Benign transient hyperphosphatasemia of infancy and childhood. South Med J. 2000 Dec;93(12):1162-4.

Yang L, Grey V. Pediatric reference intervals for bone markers. Clin Biochem. 2006 Jun;39(6):561-8.

George J, Denney-Wilson E, Okely AD, Hardy LL, Aitken R. The population distributions, upper normal limits and correlations between liver tests among Australian adolescents. J Paediatr Child Health. 2008 Oct;44(10):579-85.

Fialkowski EA, Winslow ER, Scott MG, Hawkins WG, Linehan DC, Strasberg SM.Establishing “normal” values for liver function tests after reconstruction of biliary injuries. J Am Coll Surg. 2008 Nov;207(5):705-9.

ACGME Competencies Highlighted by Case

Patient Presentation
A 2-year-old male came to clinic for a health supervision visit. His mother stated that her husband had taken another job in a distant state and they would be moving. She wanted to know how to help the 2-year-old and their 5-year-old with the transition.

The diagnosis of a family with a normative transition to a new location was made. The pediatrician asked if the children knew about the move (they didn’t yet), what type of home they would be living in (planning to move into a small home from their current apartment), childcare and school plans, and if the mother planned to work outside the home also (mother plans to stay at home currently but look for work later, older son will begin Kindergarten in the fall). The pediatrician noted that the children would experience the move differently because of their ages and that consistency and being physically available to the children was important. She discussed normal transitioning to Kindergarten expectations. She discussed safety issues inherent with traveling, the physical move and setting up a new household. She also discussed potential community services that could be accessed such as a local childcare resource and referral agency, school district, human resources office of the new company, chamber of commerce and the local realtor. The pediatrician helped the family to find another pediatrician and obtain a copy of their medical records electronically. She also reassured them that she and the practice would still be available to help them and they could call with any questions.

Discussion
Even normal life changing events can be stressful for individuals and families. Boyce categorizes transitions in this way:

• Normative or non-normative transition
  • Normative transitions are events that occur to most children and families under usual circumstances, and may be planned or unplanned
    • Entering kindergarten
    • Moving to a new location (i.e. planned moved because of new job or unplanned move because of job loss)
    • Beginning a new activity (e.g. sport, instrument)
    • Beginning a new job
    • Death of pet
  • Non-normative transitions are unanticipated events that do not occur at the normal expected time
    • Parental death
    • Divorce
• Biological and psychosocial transitions
  • Biological and psychosocial transitions often go hand-in-hand such as puberty
    • Puberty
    • Rites of passage (e.g. bar/bat mitzvah, learning to drive)
    • Moving out of the family’s home (e.g. to own apartment)
• On-time and off-time transitions
  • Transitions that are normal at one stage of life are very different if at another stage of life, i.e. the timing is off based on personal or societal expectations
    • Childbearing (different if adolescent or 20-30 year old mother)
    • Gifted student attending college at junior high or early high school age
    • School redistricting and need to change schools not at the normal time (i.e. usually Kindergarten, middle school, high school)

Families of children with complex healthcare needs may have more difficulty with transitions. One paper found that the transitions were often too focused on the transition of services needed for the individual (e.g. movement from a children’s hospital providing care to an adult hospital). Normative transitions such as moving into one’s own apartment or group facility, was hampered by lack of transition planning and collaborative decision making. Another paper found for individuals with intellectual disabilities, life events were a risk factor for psychological problems.

Learning Point
Helping children and families cope with transitions including moving can be very rewarding but what each individual needs for a smooth transition varies.

Some concepts that may assist parents with transitions include:

• Recognize that different developmental ages will experience the move, differently – in the above example the 2-year-old will probably be most interested in the here and now and therefore be very interested in the novelty of the experience and show less awareness of the loss.
  The 5-year-old will be much more aware of the loss and therefore may show sadness and grief at losing friends.

• Novelty and consistency – while the novelty of the actual move, new home, school, etc. is fun, children and adult also want consistency in their lives and environments. Therefore it is important to continue old routines (e.g. having a family meal, going for a bike ride, going to bed at a specific time, etc.) if possible. Establishing new routines and expectations early also is important (e.g. different parent picks up child from daycare, time for homework, home chores, etc.)
  Consistency in sleep, eating and activity patterns are important for children and families.

• Parents being present physically and emotionally – Children need to have parents available to them to be able to be talk and be physically close. For a young child, physical closeness predominates as the child may not verbalize the bewilderment they are feeling, but older children while more verbal may still need the physical closeness (e.g. “I just want some quiet time with you around.”). Parenting alone can bring additional challenges but often parents can find a few minutes in the day, or other time such as the weekends to set aside time specifically for the children.
• Parental sharing – parents can often help their children by sharing that they are experiencing some stress too because of the move. While parents should not burden their children, the shared experience can help the child realize that they are not alone. The parent noting that it is a difficult time for the entire family, but that they expect some very good things to happen/have happened with the move and that together as a family they can get through this difficult time, can assist everyone in the family.
  Sharing stories of other moves from parents, grandparents and friends lives also can help the child. Parents should be ready for the children to express both positive and negative emotions to the move.

• Productive outlets – Children and adults need productive outlets for their stress. This can take many forms such as drawing and coloring, writing, sports and physical activity, listening to music, talking with a friends, etc.. Whatever was helpful before the move, most likely will be helpful after the move.
  Involvement in the new community for both the children and parents can ease the transition. Some children may not have what seems to be “productive” outlets. For example, while role playing the child pretends with their dolls that they are moving and the dolls cry they don’t want go, and the child screams or even hits the dolls. This type of fantasy play has actually been shown to be advantageous for children to work out their feelings through play.

• Decreasing the rate of transitions – in the example above, the mother initially was planning on staying at home with the children but later finding work outside the home. In this way, the children don’t have to also transition to a new childcare arrangement immediately. Fewer transitions all at once may help.
• Keeping in touch with friends and family – finding way to integrate into the new community is important but also maintaining previous ties is important especially for middle school and high school students. Appropriate use of electronic communications such as instant messaging, social networking andteleconferencing can help children with the natural process of transitioning relationships across space.
• Expectations – parents need to set appropriate expectations and meaningful responsibilities for children whether or not they are in transition. Age appropriate expectations help children to develop competence and mastery. During the actual move, older children can be given responsibilities such as cleaning the floor and unpacking their room. Later, different expectations for the new living environment need to be put into place. For example a high school student may now be expected to cut the grass but that was not an issue previously when the family lived in an apartment.

Some children may not adjust well and may need professional help. . Some signs to look for include anxiety, great sadness, poor socialization, significant problems with sleep or eating, falling grades, and apathy.

Questions for Further Discussion
1. When a family is moving, what advice and tips do you offer?
2. How does your advice change for children with special health care needs or special education needs?
3. When a family is new to the area, what local agencies and organizations do you suggest to them?

Related Cases

Disease: Child Mental Health | Stress

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Psychiatry and Psychology | School | Social Services

Age: Toddler | Preschooler

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: Child Mental Health and Stress.

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

To view images related to this topic check Google Images.

Boyer WT. Coping with Stressful Transitions, in Behavioral and Developmental Pediatrics, Parker and Zuckerman eds. Little Brown and Company, Boston, MA. 1995;52-55.

Kirk S. Transitions in the lives of young people with complex healthcare needs.
Child Care Health Dev. 2008 Sep;34(5):567-75.

Hulbert-Williams L, Hastings RP. Life events as a risk factor for psychological problems in individuals with intellectual disabilities: a critical review.
J Intellect Disabil Res. 2008 Nov;52(11):883-95.

ACGME Competencies Highlighted by Case