common pediatric conditions
TRANSCRIPT
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Common Pediatric Conditions
Randy J Ferrance, DC, MD [email protected]
Chiropractor
Hospitalist: Internal Medicine & Pediatrics © 2012 RJ Ferrance, DC, MD
Otitis Media
What exactly is it?
Definition: Inflammation of the middle ear.
Acute OM – systemic and local signs, rapid onset
OM with effusion (glue ear) – persistence of effusion
beyond 3 mos without signs of infection
Chronic Suppurative – continuing inflammation cause
otorrhea through a perforated TM
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Risk Factors for OM
Young age
Attendance of day care
White race
Male sex
H/O enlarged adenoids
Tonsillitis
Asthma
Previous OM
Bottle-feeding
H/O OM in parents or
siblings
Use of a pacifier
Exposure to Tobacco
smoke
Natural Course
80% resolve in ~3days without abx*
Serious complications are rare
Hearing loss
Mastoiditis
Meningitis
Recurrent OM
51k <5y die in developing countries each year**
*Froom J, et al. BMJ 1997;315:98-102.
**World Health Organization. 1993:215-22.
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Antibiotics?
Little P, et al. Br Med J 2001
Immediate tx with abx may reduce the duration of most sx
Most of the benefit occurs after 24hrs, when the illness is
already settling.
A more discriminatory wait-and-see rx strategy has fewer side
effects and is acceptable to the majority of parents.
Antibiotics?
Mandel EM, et al. Pediatrics 2001
Meta-analysis of 80 studies
The majority of uncomplicated AOM resolves spontaneously w/o apparent suppurative complications.
Treating AOM with ampicillin or amoxicillin confers a limited therapeutic benefit
No data to support as superior any particular antibiotic at relieving sx
Certain abx are more likely than others to cause diarrhea and other adverse events
Antibiotics?
Watson RL, et al. Pediatrics 1999.
97% - overuse of abx is a major factor contributing to the
development of antibiotic resistance
78% - prior abx use increases the risk that a child will develop
a resistant infxn
69% - resistance has contributed to tx failure in my practice
58% - decision to provide abx based upon parental pressure
FPs less likely than pediatricians to report practices supported
by published principles
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Steroids?
Mandel EM, et al. Systemic steroid for chronic otitis
media with effusion in children. Pediatrics 2002.
Conclusion: Significant increase in number of children who
were effusion free after 14 days of tx with steroids and
amoxicillin c/w those who were treated with amox only.
Within 2 weeks after tx, there was no longer any significant
difference. Therefore, steroids not universally recommended
for tx of OM with effusion and tx with amox, if used, should
not continue beyond 14 days.
Naturopathy?
Sarrell EM, Cohen HA, Kahan E. Pediatrics 2003
Double-blind RCT.
171 children 5-18yrs of age
Rec’d either local anesthetic with or without amoxicillin or Naturopathic Herbal Extract Ear Drops
Abx did not significantly alter the course of the disease
Conclusions: Cases of ear pain caused by AOM in children in which active tx, besides a simple 2-3 day waiting period, is needed, an herbal extract soln may be beneficial. Concomitant abx tx is apparently not contributory.
Chiropractic?
Several case reports, only one well designed study Mills et al Arch Pediatr Adolesc Med 2003;157(9):861-866
Routine medical care plus full spine osteopathic mobilization and soft tissue procedures vs. routine care only
Treatment over 6 mo; fewer episodes AOM and surgical procedures in mobilization group compared to control
Limits: No blinding of the parents
Theory: Manipulation improves innervation and function of the tensor
veli palati, which regulates the caliber of the distal end of the eustachian tube.
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Traditional Allopathic Tx
Antibiotics
If used, Amoxicillin should be first line
Cephalosporin or Macrolide if penicillin allergic
Too often broad-spectrum drugs are used
Auralgan drops for pain
Sweet oil
Myringotomy/tubes
CDC/AAP/AAFP recommendations
Placebo-controlled trials of AOM over the past 30 years have consistently shown that most children do well, without adverse sequelae, even without antibacterial therapy.
Between 7 and 20 children must be treated with antibacterial agents for 1 child to derive benefit.
By 24 hours, 61% of children have decreased symptoms whether they receive placebo or antibacterial agents. By 7 days approximately 75% of children have resolution of symptoms.
The AHRQ evidence report meta-analysis showed a 12.3% reduction in the clinical failure rate within 2 to 7 days of diagnosis when ampicillin or amoxicillin was prescribed compared with initial use of placebo or observation (number needed to treat: 8).
http://www.aafp.org/PreBuilt/final_aom.pdf
RECOMMENDATION 1: To diagnose acute otitis
media the clinician should confirm a history of acute
onset, identify signs of middle-ear effusion (MEE), and
evaluate for the presence of signs and symptoms of
middle-ear inflammation. (This recommendation is
based on observational studies and a preponderance of
benefit over risk; see Table 2.)
CDC/AAP/AAFP recommendations
http://www.aafp.org/PreBuilt/final_aom.pdf
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RECOMMENDATION 2: The management of AOM
should include an assessment of pain. If pain is
present, the clinician should recommend treatment to
reduce pain. (This is a strong recommendation based
on randomized, clinical trials with limitations and a
preponderance of benefit over risk.)
CDC/AAP/AAFP recommendations
http://www.aafp.org/PreBuilt/final_aom.pdf
http://www.aafp.org/PreBuilt/final_aom.pdf
RECOMMENDATION 3A: Observation without use of
antibacterial agents in a child with uncomplicated AOM
is an option for selected children based on diagnostic
certainty, age, illness severity, and assurance of follow-
up. (This option is based on randomized controlled trials
with limitations and a relative balance of benefit and
risk.)
CDC/AAP/AAFP recommendations
http://www.aafp.org/PreBuilt/final_aom.pdf
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http://www.aafp.org/PreBuilt/final_aom.pdf
RECOMMENDATION 3B: If a decision is made to
treat with an antibacterial agent, the clinician should
prescribe amoxicillin for most children. (This
recommendation is based on randomized clinical trials
with limitations and a preponderance of benefit over
risk.) When amoxicillin is used, the dose should be 80 to
90 mg/kg/day. (This option is based on extrapolation
from microbiologic studies and expert opinion, with a
preponderance of benefit over risk.)
CDC/AAP/AAFP recommendations
http://www.aafp.org/PreBuilt/final_aom.pdf
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RECOMMENDATION 4: If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent(s), the clinician should change the antibacterial agent(s). (This recommendation is based on observational studies and a preponderance of benefit over risk.)
CDC/AAP/AAFP recommendations
http://www.aafp.org/PreBuilt/final_aom.pdf
RECOMMENDATION 5: Clinicians should encourage
the prevention of AOM through reduction of risk
factors. (This recommendation is based on strong
observational studies and a preponderance of benefits
over risks.)
CDC/AAP/AAFP recommendations
http://www.aafp.org/PreBuilt/final_aom.pdf
RECOMMENDATION 6: Complementary and
alternative medicine (CAM) for treatment of AOM. (No
recommendations are made based on limited and
controversial data.)
CDC/AAP/AAFP recommendations
http://www.aafp.org/PreBuilt/final_aom.pdf
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So… what’s going on in the real world?
Survey of 477 PCPs
Observation option considered “reasonable” by 83.3%
Used in 15% of cases
Barriers:
Parental reluctance
Cost and difficulty of follow-up of children who don’t improve
Vernacchio et al, Pediatrics 2007
Prevention
Antibiotics: +/-
Xylitol Gum: Good evidence
Chiropractic: No evidence
Chronic Infections Gone Away
We took the kid to a chiropractor
We took the kid to a massage therapist
We went to Colorado for Christmas
We got rid of the cats
We got rid of the carpeting and got hardwood floors
We moved to a new house
We started putting Vicks on his earlobe before he went
outside to play
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Chronic Infections Gone Away (con’t)
We started putting arnica in his cereal
We got him to chew sugarless gum
We quit smoking in the house
We gave him Tums® every night to get rid of his reflux
We got rid of the foam pillow and got a feathered one
We have him rub his head twice before he goes to bed at
night
We changed pediatricians
If I may postulate…
All AOM deserves analgesia
Naturopathic drops are a great place to start
For serous OM, consider decreasing/eliminating
dairy, other allergens
If sx worsening or not improving after 3 days,
then abx are deserved
Xylitol gum is never a bad idea
Asthma
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Asthma
Reversible airway obstruction
Airway inflammation
Increased mucus production
Bronchial smooth muscle contraction
A response to a variety of stimuli
Symptoms vary
Asthma Epidemiology
1980 – 36/1000 children
1996 – 62/1000 children
Now, defined by “Attack prevalence”
One or more episodes in the past 12mos
Rate ~ 54/1000 children
National Center for Health Statistics
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Asthma Epidemiology
Hospital visits are higher among African-
American children (3 to 4:1)
Death rate has now increased to 3.3/1 million
children in 1998
African American children at the highest risk (4-5x)
A large proportion of the increase is attributed to
more specific diagnosis
National Center for Health Statistics
Asthma Epidemiology
1200 newborns enrolled, 800 followed to 6yoa
50% never wheezed
20% had early wheezing, resolved by 3yoa
14% developed wheezing that persisted from
infancy through 6yoa
Martinez et al. Asthma and wheezing in the first 6
years of life. N Engl J Med. 1995; 332:133-138.
Asthma Epidemiology
Primary risk factor for early wheezing: Maternal
smoking
Decreased pulmonary fctn first year, usually
normalized by age 6
Primary risk factor for late onset wheezing:
Maternal asthma and being a boy
Martinez et al. Asthma and wheezing in the first 6
years of life. N Engl J Med. 1995; 332:133-138.
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Asthma Epidemiology
Risk factors for persistent wheezing:
Maternal asthma
Hispanic ethnicity
Concomitant eczema
Maternal smoking
Rhinitis not secondary to viral URIs
Being male
Elevated IgE levels were common
Martinez et al. Asthma and wheezing in the first 6
years of life. N Engl J Med. 1995; 332:133-138.
Asthma Prevalence (per 1000 children <18yoa)
0
10
20
30
40
50
60
70
80
90
80-81 85-86 90-91 95-96 97 98 99 2000
Caucasian African American
Mortality from Asthma (per 1 million children < 18yrs)
0
2
4
6
8
10
12
14
80-81 85-86 90-91 95-96 97-98
Caucasian Overall African-American
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Common Asthma Triggers
Cold air
Dry Air
Politicians’ Hot Air
Tobacco smoke exposure
Dust
Molds
Cockroach guano
Pollen
Air pollution
Viral or other infections
Animals (esp cats)
Exercise
Emotional stress
Allergens
Strong scents
Risk Factors for Asthma Death
Past Hx of sudden severe exacerbation
Prior intubation and mechanical ventilation for asthma
Prior asthma admission to the ICU
Two or more asthma hospitalizations in the past year
Hospitalization or ED visit in the last month
Use of >2 canisters of short-acting bronchodilators
Current use of system steroids or recent withdrawal from steroids
Difficulty recognizing airflow obstruction or severity
Comorbidity that may affect cardiopulmonary status
Serious psychiatric dz or psychosocial problems
Low socioeconomic status or urban residence
Illicit drug use
Chiropractic and Asthma
Balon J, et al. N Engl J Med. 1998
Conclusion: In children with mild or moderate asthma, the
addition of chiropractic spinal manipulation to usual medical
care provided no benefit.
Bronfort G, et al. J Manipulative Physiol Ther 2001
Conclusion: No improvement in lung function or
hyperresponsiveness. Positive impact on quality of life.
Examiners felt this was unlikely to be the result of the
chiropractic SMT alone, but rather other aspects of the clinical
encounter. Recommended further research.
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Chiropractic and Asthma
Guiney PA et al J Am Osteopath Assoc 2005 Osteopathic mobilization led to improvement in peak expiratory volume.
No comment on medication use or symptomatology
Only study which showed any change in physiological measurements
Hondras MA, Linde K, Jones AP. Cochrane Database
Syst Rev 2002 Conclusion: Insufficient evidence to support the use of manual therapies in
patients with asthma. There is a need to conduct adequately-sized RCTs
that examine the effects of manual therapies on clinically relevant
outcomes. Insufficient evidence to support or refute the use of manual
therapy for patients with asthma.
“But…chiropractors cure asthma all the time!!”
Paradoxical vocal cord motion (PVCM) Episodic laryngeal dyskinesia, VCM
Vocal cord adduction during inspiration/expiration causing a functional extrathoracic airway obstruction.
Symptoms include: wheeze, cough, dyspnea, SOB
More common than is appreciated, diagnosis frequently not considered.
Often confused with asthma and misdiagnosed.
Much morbidity caused from misdiagnosis.
Newman et al studied 95 patients with proven PVCM
Asthma was misdiagnosed an avg. 4.8 years, 28% intubated
Demographics
Juveniles – under age 18
2 studies at different institutions found:
Average presenting age: 14.6 (range 9.0 – 18.0)
82-86% of patients female.
Similarities among patients included: organized sports,
social stressors, exercised-induced symptoms.
Powell et al found strong association with GERD.
Laryngospasm likely 2º reflux irritation but cause-effect
relationship is yet established.
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That postulating thing again
If there is thoracic cage restriction, manipulation is warranted
Some asthmatics can be “talked down”
Many asthmatics aren’t
All that wheezes is not asthma
Consider VCD and just plain deconditioning
First line therapy should always be environmental modification
Be careful what you promise
Allergies and Whatnot
Atopic Dermatitis
Incidence increasing with time
Now: 12-15% of pediatric population
Begins in infancy
Extreme pruritis
Chronically relapsing course
Distinctive distribution
50% develop in the first year of life
80% by 5yrs
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Atopic Dermatitis
80% develop asthma or allergic rhinitis
Many lose AD after the onset of respiratory sx
Acute rash:
Erythematous
Papulovesicular eruption
Frequently weeping and crusting
Progresses to subacute form with erythema and scaling
Lichenification
Atopic Dermatitis
85% have elevated serum IgE
85% of those have specific IgE to food and inhalant
allergens
91% have a positive family hx of atopic dz
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Atopic Dermatitis and Food Allergies
Food + Challenge +Hx Total %
Egg 178 35 213 57
Milk 96 47 143 38
Peanut 28 82 110 29
Soy 55 4 59 16
Wheat 43 0 43 11
Sampson HA. J Allergy Clin Immunol. 1988 n=470 children with AD
Food Allergy Cross Reactivity
Primary Allergy Associated Allergy %
Peanut Other Legumes 3-5%
Cereal grains Other grains ~20%
Egg Chicken ~5%
Cow’s Milk Goat’s Milk 90%
Cow’s Milk Beef 10%
Beef Lamb 40%
Sampson HA, Sicherer SH. Immunology Clinics
of NA. 1999
Reducing the risk
No peanuts, nuts, fish, shellfish, soybeans for the
first two years
Breastfeed as long as possible
Mom avoids eggs, milk, peanuts.
Solid foods delayed until 6 mos
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Determining the Culprit
Trial of food withdrawal
Trial of food challenge
Do NOT challenge at home if anaphylaxis is
suspected
RAST testing
Colic
Chiropractic Tx thereof
Chiropractic seems to work with colic
Wiberg et al – JMPT – 1999;22:517-22
Chiropractic seems not to work with colic
Olafsdottir– J Pediatr – 2001 Sep;139(3);467
So, some is and some isn’t?
Could there be selection bias?
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Galen (c130-210AD)
All who drink of this remedy recover in a short time, except those whom it does not help, who all die. Therefore, it is obvious that it fails only in incurable cases.
Crying
The primary form of communication for babies
Equal across cultures
Nature is the clue: Piercing, “like they’re in
pain.”
To parents, unconsolable crying is colic
Medical Research
BMJ systematic review of treatments in 27
controlled trials for infantile colic showed NO
effective treatment EXCEPT dicyclomine which
had side effects too serious to consider using as
treatment
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Chiropractic Literature Review
Nilsson reported in 1985 in Denmark a retrospective uncontrolled study of 132 infants with colic that 91% reported improvement after 1 week of chiropractic treatment
Mercer and Nook reported in 1999 that CMT is more effective than placebo in a controlled trial of 30 infants in Australia
What the studies show:
Klougart (1989): SMT successful in 94% or 316 cases with mean of 3 treatments
Wiberg (1999): SMT is significantly more effective for colic symptoms than dimethicone (50 infants)
Olafsdottir (2001): no significant difference between SMT (70%) improved and placebo (60% improved) in 86 infants
Bolton (2002)-review of literature: chiropractic care is a reasonable approach to colic
What the studies show:
Savino (Pediatrics 2007): oral administration of
Lactobacillus reuteri was superior to simethicone
Keefe (Clin Pediatr 2006): Home intervention
was superior to conventional care
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Colic
Infant usually 3 weeks to 3 months of age
Cries more than 3 hours a day,at end of day
More than 3 days a week
More than 3 weeks
Baby is otherwise growing, thriving and healthy
CMPI
Cow’s milk protein intolerance occurs in 6% of infants and differs from colic
Symptoms most commonly occur at 13 weeks
Family history of two 1st degree relatives who are atopic
Diet elimination with provocation recommended
Irritable Infant Syndrome- Musculoskeletal Origin
(IISMO)
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Physiologic Components of IISMO
Hypertonia
Arching Extensor posture
Limb hyperactivity
Restless sleep
General unrest
Unusual posture
Chiropractic Care
Adjust the infant
Tummy massage
Suggest postures for infant comfort
Empathize with the parents
Explain the problem in a meaningful way
Advise breaks for the mother
Constipation/Encopresis
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How we poo
Inflation Reflex (seen after age 2)
Distension of rectum
Stimulus via sensory nerves
Conscious awareness
Transient relaxation of external anal sphincter (EAS)
Rectosphincteric Relaxation Reflex Distension of rectum
Sensory nerves (via myenteric plexus)
Inhibition of smooth muscle internal anal sphincter
Relaxation of IAS
Problems with Poo
Three Groups
Stool toileting refusal
Fecal incontinence due to anatomic, neurologic,
inflammatory causes
Functional encopresis due to constipation
Accounts for 90% of encopresis in children
3% of visits to general pediatric clinics
25% of referrals to pediatric gastroenterologists
Functional Encopresis
Prevalence: 4yrs: 2.8%
6yrs: 1.9%
10-11 yrs: 1.6%
Rare after 16years
Common spontaneous remission
Toileting Refusal: Ability to urinate but not stool in the toilet for >1mo
½ will end up with functional constipation
Anorectal malformations: 1/8000 children
Meningomyelocele: 1/1000 children
Hirschsprung Dz: 1/5000 children
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Evaluation
Complete Hx Intervals (stool-free interval after large stool)
When was onset?
Size, consistency
Is diarrhea present?
Does stool clog the toilet
Abdominal pain, previous surgery, enuresis
Diet hx
Coercive toilet training
Social Stressors
Decreased fluid
Problems in the toilet at school
Evaluation
Physical Examination
Weight, height, abdominal, rectal, neurological exam
Look for fecal mass, LLQ
Inspect anus
Soiling, scarring, location, patulous, check for anal
“wink”
Plain film of abdomen
Red flags to keep in mind
> 48 hours before passing first meconium
Abdominal distension, especially if associated with failure to thrive
Infrequent small or ribbon stools
Constant leaking of stool, especially if associated with urinary leakage
Failed management with appropriate standard intervention (assuming full compliance)
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Anatomical Problems
Ano-rectal malformations, stenosis, atresia with perineal fistula, postnatal atresia repair
Usually present with small calibre BMs
Myelomeningocele, tethered cord, tumor, trauma, infection
Hx of major day and nighttime urinary incontinence
Hirschsprung dz: Male:female ration 4:1
Mean age at dx down from 19mos to 3 mos
Constipation from birth, distension, vomiting, diarrhea
Management
Toilet Refusal
Put diapers back on
89% of pre-school children stool in toilet <3mos
Laxatives or suppositories can be used to make stool
withholding difficult
Resolves without intervention in <6mos
Another 19% resolved >6mos
Luxem MC, Christophersen ER, Purvis PC, et al.
Behavioral-medical treatment of pediatric toileting refusal.
J Dev Behav Pediatr 1997;18:34-41.
Management
Fecal Incontinence
If anatomical cause, toilet regularity is important
Dietary fiber
Scheduled toileting
Daily administration of senna
Emptying of rectum with suppositories or manually
No randomized studies for tx in children with anatomical or
neurological impairment
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Management
Functional Encopresis
Education
Clearing the impaction
Preventing recurrence
Timed toilet sitting 15-30 mins after meals
Daily laxatives to prevent future impactions
Functional Encopresis - Education
Demystify the problem
Support
Encourage
Non-blaming environment
Positive reinforcement
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Functional Encopresis – Clear the Impaction
Manual disimpaction
Enemas
Laxatives
Bulking agents
Softening agents
Synthetic sugars
Emulsificants
Stimulants
Functional Encopresis – Preventing Recurrence
Encouragement
Positive Reinforcement
Make use of the gastrocolic reflex
Daily laxatives until stable
Vigilance
Laxatives
Bulking and softening agents Indigestible plant products, distend the intestine to increase
peristaltic activity
Psyllium, Malt soup extract
Emolients Keep stool moist
Docusate, mineral oil
Synthetic Sugars Act as osmotic agents, retaining water to soften stool
Lactulose, polyethylene glycol
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Laxatives
Stimulants
Stimulate peristalsis via alkaloids
Work 6-8 hours later
Senna, bisacodyl, Milk of Magnesia, Magnesium citrate
Enemas
Stimulate expulsion, emulsify stool
Mineral oil, tap water, soap suds, HHH, sodium phosphate,
milk and molasses
Dosages of Laxatives for Constipation and Encopresis
Data from Luxem MC, Christophersen ER, Purvis PC, et al. Behavioral-medical treatment of pediatric toileting refusal. J Dev
Behav Pediatr 1997;18:34–41, with permission; Lowe JR, Parks BR Jr. Movers and shakers: a clinician's guide to laxatives. Pediatr
Ann 1999;28:307–10, with permission; and Loening-Baucke V. Clinical approach to fecal soiling in children. Clin Pediatr
2000;39:603–7, with permission.
Laxative Age of Child Dosage Comments
Bulking agents
Psyllium 6–12 yr 2.5 g 1–4 times daily
>12 yr 5 g 1–4 times daily
Malt soup extract Breast-fed
infants
5–10 mL in 2–4 oz In water or fruit juice 2 times daily
Bottle-fed
infants
5–10 mL every 2nd
feed
Emollient
Docusate (Colace) <3 yr 10–40 mg/d 1–2 divided doses
3–6 yr 20–60 mg/d 2–3 divided doses
7–12 yr 40–120 mg/d 2–3 divided doses
>12 yr 50–200 mg/d 2–3 divided doses
Mineral oil >6 mo 1–5 mL/kg/d 1–2 divided doses
Synthetic sugars
Lactulose >6 mo [10 g/15 mL] 1–2
mL/kg/d
2–3 divided doses
Polyethylene glycol 3350
(Miralax)
? 0.5–1 g/kg 1–2 divided doses
Laxatives
Senna 2–5 yr 5–10 mL Both at bedtime using syrup, tablets,
granules
6–15 yr 10–15 mL
Bisacodyl (Dulcolax) 6–12 yr 5 mg tablet or
suppository
Once daily
>12 yr 10 mg tablet or
suppository
Once daily
Milk of Magnesia >6 mo and <12
mo
1–3 mL/kg/d 1–2 divided doses
≥12 mo 60 mL Twice daily
Enemas
Mineral oil <12 yr 1–2 oz/20 lb of weight Squeeze bottle (4.5 oz)
≥12 yr 4 oz
Sodium Phosphate
(Fleet)
<12 yr 1 oz/20 lb of weight Squeeze bottle (2.25 oz child, 4.5 oz
adult)
≥12 yr ≥12 yr/4 oz (maximum
8 oz)
Laxative Age of Child Dosage Comments
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Fever in the Neonate
Chiropractic Treatment
Lee AC Arch Pediatr Adolesc 2000;154(4):401-7.
70% of chiropractors responding recommended herbs and
dietary supplements to their pediatric patients.
30% actively recommended childhood immunizations
Presented with a hypothetical 2wk old neonate with fever,
17% said they would treat the patient themselves rather than
immediately refer to an MD, DO or ER.
Of those who were “peer-recommend” 62% said they would
not refer an infant with fever to an MD
Why that frightens me
85-98% of infants with a fever (>100.5) have a viral
syndrome or some other benign process
A small number will have a bloodstream or CNS
infection
Morbidity and mortality is rare, but serious
4-6% will suffer debilitating injury or death if untreated
Several studies over the past ten years to better delineate
which patients are most at risk
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Current Recommendations…
Infants under the age of 30 days should be treated
conservatively
Hospital admission
Urine, blood, CSF Cultures
IV Abx until 72hrs of negative cx
Current Recommendations… (2)
Infants 1-2 mos can avoid hospital admission if:
O/w benign physical examination
Benign Laboratory findings
No significant risk factors
Benign Laboratory findings
Normal urinalysis
WBC 5,000-15,000
If diarrhea is present, no heme or WBCs in stool
CSF of <10wbc/hpf (If LP performed)
CSF of <8wbc/hpf if bloodless
Negative CSF gram stain
Band: neutrophil <0.2
No infiltrate on CXR
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Risk Factors
High risk
Preemies, NICU grads, congenital heart/lung dz
Low risk
Do not appear toxic, have no obvious source of fever
Reliable caregiver and transportation
Most Common bugs <60 days
Group B streptococci
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
Listeria monocytogenes
Escherichia coli
Resources and stuff
Christopher N, Congeni J, Overuse Injuries in the Pediatric Athlete: Evaluation,
Initial management and strategies for prevention. Clinical Pediatric Emergency
Medicine. 2002: 3(2)
Stanitski CL: Pediatric and adolescent sports injuries. Clin Sports Med 16:613-
633, 1997.
Micheli LJ, Fehlandt AF: Overuse injuries to tendons and apophyses in
children and adolescents. Clin Sports Med 11:713-726, 1992.
Ireland ML, Hutchinson MR: Upper extremity injuries in young athletes. Clin
Sports Med 14:533-569, 1995.
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Resources and stuff Baumgaertel A. Attention-deficit/Hyperactivity Disorder. Ped Clinics of NA
(46) 977-92. 1999.
Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for acute otitis media?
A review from the International Primary Care Network. BMJ 1997;315:98-
102.
World Health Organization. World development report 1993: investing in
health. Oxford: Oxford University Press, 1993:215-22.
Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O’Shaughnessy D,
Walker C, Goldsmith CH, Duku E, Sears MR. A comparison of active and
simulated chiropractic manipulation as adjunctive treatment for childhood
asthma. N Engl J Med. 1998 Oct 8;339(15):1013-20.
Bronfort G, Evans RL, Kubic P, FIlkin P. Chronic pediatric asthma and
chiropractic spinal manipulation: a prospective clinical series and randomized
clinical pilot study. J Manipulative Physiol Ther 2001 July-Aug;24(6):369-77.
Resources and stuff Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane
Database Syst Rev 2002;(4): CD001002.
Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic
randomized controlled trial of two prescribing strategies for childhood acute
otitis media. Br Med J 2001;322:336-342.
Mandel EM, Casselbrant ML, et al. Systemic steroid for chronic otitis media
with effusion in children. Pediatrics 2001; 108:239-247.
Watson RL, Dowell, SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B.
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