Pediatrics/Pediatric Surgery

18.1 Bronchiolitis/RSV

Peds 1999;104:1334; Nejm 2001;344:1917; Am Fam Phys 2004;69:325

Cause: Respiratory Syncytial Virus (RSV).

Epidem: Peak incidence from November-April. Major issue in immunocompromised, premature infants, and cardiopulmonary disease in peds < 2 yr of age (Jama 1999;282:1440).

Pathophys: Bronchial infection/reactivity.

Sx: Respiratory distress.

Si: Tachypnea with wheezing.

Crs: Refractory course despite β-agonist treatment almost defines this disease process; fever associated with more severe clinical course (Arch Dis Child 1999;81:231). Lifelong increased chronic course of airway hyper-reactivity in children if bronchiolitis after 1 yr of age (Am J Respir Crit Care Med 2000;161:1501), but this is not found if disease affects one only as an infant (< 12 mon of age) (J Peds 1999;135:8).

Cmplc: Respiratory failure.

Diff Dx: Adenovirus; parainfluenza virus; foreign body; pneumonia; human metapneumovirus (Nejm 2004;350:443); cystic fibrosis, if recurrent; occult bacteremia in children 2-36 months of age
is rare, and the approach of routine pan-culture is not supported by current literature (Arch Ped Adolesc Med 2004;158:671).

Lab: Nasal wash RSV; capillary blood gas, pulse oximetry, and CXR, if significant distress.

Emergency Management:

Isolation—prevent nosocomial spread.
O₂; iv fluids, if in extremis.
Nebulized racemic epinephrine (1 mg in 2 cc NS) in extremis (J Peds 1993;122:145) although routine use of 4 cc of 1% epinephrine nebulized with 3 treatments q 4 hr did not impact length of stay or ability of early for early discharge from hospital in those admitted (Nejm 2003;349:27).
Albuterol neb 2.5 mg per treatment or 10 mg/hr continuous.
Consider steroids (controversial)—parenteral, oral, or inhaled—parenteral study (Peds 2000;105:E44) vs budesonide inhaled study (Arch Dis Child 1999;80:343) and fluticasone inhaled study (Eur Respir J 2000;15:388).
Heliox (70:30 Helium:O₂) may be of some benefit for both clinical severity score and need for ICU in those with moderate to severe symptoms—age group 1 mon to 2 yr (Peds 2002;109:68).
Nitric oxide data are equivocal (Intensive Care Med 1999:81).
Pediatrics consult for admit if not responding or stable, may need intubation +/− aerosolized ribavirin as inpatient—con (Am J Respir Crit Care Med 1999;160:829).
Next day follow-up with peds if well enough to go home, consider home albuterol nebs (every 3-4 hr). Outpatient follow-up may include RSV immune globulin (each month in high-risk infants).

18.2 Cat-Scratch Disease (a Form of Cervical Adenitis)

Ped Infect Dis J 1997;16:163; 1985;4:S23

Cause: Bartonella (Rochalimaea) henselae and quintana, a small pleomorphic Gram negative, probably rickettsial organism. Sometimes Afipia felis (J Clin Microbiol 1998;36:2499).

Cervical adenitis itself is usually a self-limited viral (adenovirus, enterovirus, CMV, Epstein-Barr, herpes simplex) disease which resolves quickly, but can be caused by Staphylococcus, Streptococcus, and anaerobes (Clin Peds (Phila) 1980;19:693); less likely anaerobes, atypical organisms, cat-scratch disease, and toxoplasmosis.

Epidem: From young cats, infected for a few weeks; transmit via bites, scratches, and fleas, thus common name is a misnomer. 80% of cases in pts under age 21.

Pathophys: 7-14 d incubation. Bartonella spp. also found in bacillary angiomatosis and bartonellosis (Int J Dermatol 1997;36:405).

Sx: Bite or scratch from kitten (90% positive); papule at site of scratch.

Si: Fever; signs of scratch or bite with papule noted; adenopathy with 40% of nodes suppurative; potentially many ocular findings including Parinaud’s oculoglandular syndrome (infection of eye surface and regional lymphadenopathy) (Curr Opin Ophthalmol 1999;10:209).

Crs: Usually self-limited, even with complications.

Cmplc: Encephalopathy (J Peds 1999;134:635); encephalitis (10%); osteolytic bone lesions; conjunctivitis; purpura; mesenteric adenitis.

Immunocompromised patients: disseminated disease; bacillary angiomatosis—looks somewhat like Kaposi’s sarcoma; peliosis hepatitis—sometimes seen in the immunocompetent.

Diff Dx (rare): TB and other mycobacterium (Clin Peds (Phila) 1997;36:403); Haemophilus influenzae; syphilis; fungal; Yersinia pestis.

Lab: CBC with diff showing mild eosinophilia; ESR; liver function tests, if systemically ill; obtain CSF, if neuro changes and look for increased protein; Rochalimaea henselae titer of > 1:64 is 84% sensitive and 96% specific. PCR may be needed (Hum Pathol 1997;28:820).

Emergency Management:

Mild disease (only papule at site):

No rx, outpatient follow-up in 2-3 d with primary physician.

Moderate/severe disease:

Ciprofloxacin 500 mg po bid; or azithromycin 500 mg d 1 followed by 250 mg d 2-5 (pediatrics—10 mg/kg d 1 followed by 5 mg/kg d 2-5) (Ped Infect Dis J 1998;17:447)
Pediatrics—TMP/SMX (4 TMP/20 SMX per kg per dose) bid to a max of 160 TMP/800 SMX.
Erythromycin 500 mg po qid for disseminated forms; second line is Doxycycline 100 mg po bid.
May also consider gentamicin, ceftriaxone, cefotaxime, or amikacin.
Primary care consult for admission, if moderate or severe disease.

18.3 Child Abuse

Hosp Community Psychiatry 1992;43:111; J Med Assoc Ga 2000;89:5

Cause: Potentially anyone—parents, caregivers, strangers.

Epidem: Linked to parental unemployment/poverty, especially fathers (Child Abuse Negl 1998;22:79). Adolescent mothers at higher risk than older counterparts, especially if they had been abused (Child Abuse Negl 2000;24:701). False allegations or misinterpretation uncommon (2.5%) (Child Abuse Negl 2000;24:149).

Pathophys: Abuse or neglect in the physical, sexual, or emotional (verbal) realm.

Sx: Sleep disorders; nightmares; inappropriate sexual play; school and developmental problems; phobias; depression.

Si: Delay in seeking rx. Recurrent injury; patterned bruises; fractures; head injuries; retinal hemorrhages; facial and oral injuries (Child Abuse Negl 2000;24:521). Injuries inappropriate for age, not consistent with hx, and to different body planes.

Crs: Potentially fatal; intervention requires a team approach with state agencies, police, social work, and other specialty organizations.

Cmplc: Failure to thrive; may impact all aspects of life, including long-term neurobehavioral problems (J Child Psychol Psychiatry 2000;41:97).

Lab: Consider radiographic bone survey if evidence of trauma (J Am Acad Orthop Surg 2000;8:10); forensic photos.

Emergency Management:

Pediatrics consult for admission.
Department of health/human services referral.

18.4 Croup

Nejm 2001;344:1917; Ped Pulmonol 1997;23:370; Ped Clin N Am 1999;46:1167

Cause: Parainfluenza virus, and others.

Epidem: 3:100 under age 6 yr; 1.3% must be hospitalized; adult croup does exist (Chest 1996;109:1659).

Pathophys: Two forms, and both occur mainly at night with child in recumbent position—whether this is due to fluid shifts with consequent edema or meridian causality is unknown.