Mastering Pediatrics: Abdominal Pain

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Abdominal pain has a huge differential diagnosis which changes based on age, gender, and acuity among other variables. It also can encompass referred pain from the back, thorax and pelvic/genitourinary structures, or be a complaint for a general systemic illness.

    Acute gastroenteritis or constipation are two of the most common reasons for abdominal pain.

    History can be helpful with crafting a differential diagnosis and evaluation/treatment plan. Some details include:

    • Is the abdominal pain acute or chronic overall
    • Timing and duration of the actual pain
    • Location of the pain and possible radiation
    • Has accompanying symptoms such as fever, nausea, vomiting, diarrhea, cough, genitourinary symptoms or muscle pain
    • Symptoms are interfering with activities of daily living such as sleep or eating
    • Treatments that are relieving symptoms
    • Any genital symptoms including possible pregnancy

    Red flag symptoms suggesting a possible surgical abdomen include:

    • Pain that is sudden, severe, persistent, or out of proportion for history or rest of physical examination
    • Persistent emesis especially that is bilious
    • Bowel obstruction pattern with inability to pass gas or stool
    • Bleeding including hematemesis, hematochezia, or melena
    • Peritoneal signs, bloating, ascites, or point tenderness on examination
    • Masses including pregnancy
    • Hemodynamic instability or fever

    It is also good to think about possible problems from different age groups. For example, acute cholecystitis is much more common in adults but certainly can occur in the pediatric age group. Intestinal malrotation is usually considered in infants but may not occur until an older age group because volvulus does not occur until that time.

    Another phenomenon to consider, especially in the late school age/early adolescent age, is normal body sensations. Around this time, children seem to have a heightened awareness of their body and sensations such as abdominal fullness after eating, rectal emptiness after a bowel movement, or just normal gastric motility and may complain and seek care. Some children, teens and adults also seem to have more forceful gastrointestinal motility or heightened sensitivity to it and therefore experience pain with what is normal bowel motility.

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

Mastering Pediatrics: Failure to Thrive

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Growth parameters are important vital signs for children and teenagers and in children we monitor weight, length and head circumference. Pediatricians may seem obsessed with growth parameters as we are always evaluating them for every clinical encounter.

    Importantly, if a child is growing well, then likely they actually are well and do not have significant underlying disease. When the growth parameters are not tracking, then the reason for that needs to be elucidated.

    Failure to thrive means persistent weight below the 3rd percentile for age in infants and young children or that the rate of weight gain is significantly below expected standards for their age and sex.
    Failure to thrive does not mean that the child is small if they are growing at the appropriate velocity for their age, gender and genetic potential. Two good references for growth velocities can be found Guo et.al., DOI: 10.1016/s0022-3476(05)82045-1 and Kalberg et.al., DOI: 10.1016/s0022-3476(05)82045-1

    Not gaining weight usually is due to three major categories:

    • Not enough calories getting into the body, e.g. not eating enough, regurgitation, serial or multiple illnesses
    • A processing or metabolic problem within the body, e.g. increased metabolic needs like fever, significant trauma, etc.
    • Food not being absorbed for some reason, e.g. diarrhea, inflammatory bowel disease, short gut syndrome, etc.

    The cause may be easily identified (e.g. child with oral aversion), or quite often is multifactorial with more than one of these major categories being involved.

    Evaluation includes a comprehensive history, physical exam and at least basic laboratory testing. It may include more extensive testing, including a bone age for the child. A social history is always important to determine if there is unrecognized food insecurity within the household, different types of feeding practices or beliefs where the child may not be being provided adequate nutrition, or if there is frank child neglect.

    Treatment starts by trying to identify and treat the underlying causes. Increasing calories in an appropriate manner for the age, circumstances, and personal and cultural preferences is also usually started. For example, increasing the caloric density of breast milk or formula for infants, calorie boosting for older children and teenagers by adding calorically dense foods to the diet (e.g. often dairy products, oils, nut butters, additional protein, etc.). Nutritional supplements (i.e. Pediasure® Ensure® Carnation Instant Breakfast®) can also be used. For some special needs children, enteral feeding is needed. Those with some type of oral aversion can also work with feeding specialists.

    Food is expensive and special diets can add to the costs which can be financially difficult for families. Social workers may be able to identify additional food, financial and other resources to assist the family.

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

Mastering Pediatrics: Fever

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Fever not only makes children and teenagers feel bad. Parents really dread fevers because they worry about what is causing the fever, and kids being sick disrupts the entire household.

    A true medical fever is >100.5F or 38C. Parents will often think that any temperature more than 98.6F or 37.5C is a fever, but this is a temperature elevation.

    Most fevers are usually caused by an acute, self-limited illness, that can be treated at home such as a viral illness. Sometimes it is a bacterial illness such as an ear infection or strep throat that needs antibiotic treatment. Fever has a very large differential diagnosis and can always be the sign of a significant disease process.

    Assuming that there is a self-limited illness parents can be educated saying something like the following:
    Fever is a good thing. It is telling us that the body knows there is something wrong and is trying to take care of the problem.
    But fever can make the patient feel bad. Patients do not want to drink, they are in pain, or they just have that non-specific, “I don’t feel good” or “oogly feeling”.
    If fever is causing real discomfort then it can be treated with antipyretics like acetaminophen or ibuprofen. It will make the child feel better.
    But just because the patient has a fever they do not have to be treated with antipyretics. If they are acting well, they can just be watched. Antipyretics are there for the patient’s comfort.

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

Mastering Pediatrics: Diarrhea

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Diarrhea is usually defined as loose, watery stools that are more than 3 times a day, or much more than the usual frequency for the person. Usually this equates to a Bristol Stool Scale of 6 or 7.

    The differential diagnosis is large, but often is infectious with one of the most common causes being viral enteritis.Usually diarrhea is short-lived with resolution in a few days.

    An important point to remember that viral enteritis is the most common cause of bloody diarrhea overall. Blood in the stool is more likely to occur in any given case with bacterial diarrhea like Salmonella, Shigella, Yersinia, Campylobacter, Clostridium, and E. coli or parasitic infections like Entamoeba. However these infections do not happen as often as viral enteritis. Although bloody diarrhea is less likely to occur in any given case of viral enteritis, there are so many more viral infections than bacterial or parasitic infections, that the viral enteritis is the most common cause of bloody diarrhea.

    Gastroenteritis is not the same as enteritis and gastritis. Enteritis is the diarrhea; gastritis is the emesis. If the patient has both then it becomes gastroenteritis. This is important because the differential diagnosis is different for all 3 problems. There is much overlap though.

    Especially in children, patients can become dehydrated quickly with ongoing fluid losses. Evaluation of hydration status needs particular attention. Objectively weight changes are the best data sources. Physical examination findings such as slow capillary refill, poor skin turgor, and tacky mucous membranes also help with hydration evaluation. Urination is also a helpful measure by noting its frequency and sometimes its volume. It can be difficult to tell if a child has urinated because of mixed urine/stool, especially in diapered children. One can try to place cotton balls to create a “diaper dam” between the urethra and anus to try to identify urination frequency. In males, the penis can also be pointed toward the top of the diaper and that area checked for urine as it is less likely to be contaminated with stool.

    It is notoriously hard to evaluate stool volume. Most people are not diapered and even if they are weighing the diapers is very hard to do. Estimations of stool frequency through how many toiletings or diaper changes can assist. If diapered, volume can be estimated if parents describe them as “a blow out” or leaking outside the diaper.

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AI Generated Learning Materials from PediatricEducation.org Content (not reviewed)

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