Post on 31-Mar-2015
Tales from the ER Follow Up
Clinic
Tales from the ER Follow Up
Clinic
Dr. John MartinOctober 6, 2013Dr. John Martin
October 6, 2013
ER Follow Up ClinicER Follow Up Clinic
Review some common patients over the last 6 months
Talk about some common misconceptions about some of these cases
Look at some of the current evidence for treating these patients
BackgroundBackground
Developed in early 2000 by Dr. C. Enriquez (ER) and Dr. J. O’Dea (peds)
Identified need for specific patient group who needed quick follow up after being seen in the ER
Expanded to 2 clinics (Tuesdays and Fridays)
I became involve in March 2012
Case #1Case #16 week old presents with 2/7 history of diarrhea and rectal bleeding x 2 that day
Previously well
Feeding well -- very “spitty” after feeds for the last 3-4/52
Mom states baby has “projectile” vomiting at times
Formula fed
Case #1Case #1
Have switched formulas 5 times in the last 3 weeks on the advice of multiple sources
Rest of history unremarkable
Normal physical exam
Weight gain great - averaging 35 grams/day
Mother is +++ concerned baby is “allergic to formula”
Case #2Case #24 month old infant, breast fed for first 2.5 month
Mom starting introducing formula about 1 month ago
1-2 bottles per day
about 10 days ago - 8-10 episodes per day of bright green “mucousy” explosive diarrhea
Fine red rash between nipple line and distal femurs
Seen in ER -- treated for diaper dermatitis
F/U in 5/7 if no improvement
Return to exclusive breastfeeding during that time
Case #2Case #2Returned to ER 5/7 later -- no improvement in terms of diarrhea
Gassiness/Fussiness -- greatly improved. Rash gone
Diaper dermatitis -- resolved mostly
Good weight gain over 5/7
Stool samples -- C&S, viruses and C. Diff.
Switch to Alimentum / Eliminate cow’s milk completely from mom’s diet
Follow up in Resident’s clinic
Cow’s Milk Protein Allergy
Cow’s Milk Protein Allergy
Fairly uncommon entity (incidence estimated to be less than 3%)
Some (breast fed) population studies state it is as low as 0.15%
Symptoms may occur in up to 20% of the populations
Symptoms start within the first month of life, usually a week after the introduction of formula
Cow’s Milk Protein Allergy
Cow’s Milk Protein Allergy
Large differential
Anal fissures
Gastroenteritis
Diaper Dermatitis
Transient Cow’s Milk Intolerance
Cow’s Milk Protein Allergy
Cow’s Milk Protein Allergy
Two versions
Type I hypersensitivity - IgE mediated - significant effects
Urticaria, wheeze and vomitting present within hours of ingestions
Non-IgE mediated - present with similar features - usually at least 2 systems affected
50-60% Gastrointestinal symptoms (N/V/D/colic)
50-60% MSK features (atopic dermatitis, urticaria)
20-30% Respiratory symptoms (rhinoconjunctivist or wheeze)
Cow’s Milk Protein Allergy
Cow’s Milk Protein Allergy
To diagnose -- completely eliminate cow’s milk from diet
Formula fed infants - switch to a hydrolyzed formula
Breast Fed infants - completely eliminate cow’s milk from mother’s diet
After elimination period (~two weeks or more), reintroduce to see if symptoms return.
Lactose IntoleranceLactose IntoleranceAlways in the differential for “milk allergy”
Loose watery explosive diarrhea after the ingestion of cow’s milk (lactose)
Congenital Lactose Intolerance is extremely rare (case reports only)
Primary Intolerance - presents in infancy/childhood
Secondary Intolerance - follows a trigger (gastro, chemotherapy etc)
ManagementManagementIf it is a true CMPA -- eliminate cow’s milk from the diet
Breast Fed infants -- completely eliminate it from mother’s diet
Formula fed - switch to a hydrolyzed formula
Alimentum, Nutramigen, Neocate
No value in switching to soy
Cross-reactivity is described between 20-50%
ManagementManagement
Involvement of dieticians is very useful
Ensuring optimal nutrition of baby (and mother)
Re-introduction of cow’s milk after 1 year
~2/3 will tolerate reintroduction at 1 year
~85% will tolerate by 2 years
95%+ will tolerate by 3 years
Mother’s questionsMother’s questionsMy formula doesn’t have DHA/AA in it --- does that matter?
Omega-3 acids are felt to improve brain and eye development
Naturally occurring in breast milk
No evidence to suggest that adding these to formula has any benefit
Formulas with these additives cost more
Case #1Case #1By the time they were seen by me, diarrhea and bleeding had settled
Reflux was still an issue
Counselled about the importance of good feeding and burping techniques
Switch back to an iron-fortified formula
Followed up again after two weeks - reflux had mostly settled
Case #3Case #3
Seen in clinic 10/7 later
No change
Continues to have diarrhea (no blood)
Investigations are normal (BW done after clinic visit)
Cultures were negative
Case #3Case #34 week old infant -- referred for noisy breathing
Present basically since birth
Reassured by 5NB pediatrician, family doctor and public health nurse - baby is just a bit “mucousy”
“Gasping at times” - mother +++ worried that baby was going to stop breathing
Case #3Case #3
No cyanosis, no wheezing/grunting, no feeding issues
Birth history - remarkable
On exam - Beautiful “robust” baby
No distress - no accessory muscle use
Completely normal exam
Case #3Case #3
While talking to the parents after hearing the history/examining the patient
Baby is lying on the bed, 3/4’s asleep --- hear a very tiny squeak
Mother exclaims --- “That it!!!!”
LaryngomalaciaLaryngomalaciaMost common cause of stridor in infancy
Up to 75% of infants with stridor
Area of obstruction above the larynx
Presents in the first few weeks of life (usually by 4 months of age)
Can be worsened with feeding/crying/lying flat on back/sleep
Suck-Swallow-Breath reflex is a challenge in these infants
LaryngomalaciaLaryngomalaciaMultiple theories on why infants have this - anatomic abnormalities, cartilaginous variations and neurologic causes
Easy diagnosis -- perform flexible laryngoscopy in the office
40% of infants will be mild in nature
More severe case may need more aggressive management - feeding/weight gain may be significant issues
By 12-18 months symptoms will resolve
Case #3Case #3
Seen by ENT the next day
Performed flexible laryngoscope in clinic
Confirmed diagnosis of laryngomalacia
Clinic note - omega shaped epiglottis
Started on ranitidine suspension - 4mg/kg
Normal and Omega Shaped Epiglottis
Normal and Omega Shaped Epiglottis
Normal and Tubular Epiglottis
Normal and Tubular Epiglottis
Everyone of these patients come back on Ranitidine???Everyone of these patients come back on Ranitidine???
Clinically not suspicious of a diagnosis of reflux
ENT -- “There is some pretty good evidence for reflux in laryngomalacia”
What is the evidence for treating patients with laryngomalacia with anti-reflux medications??
Severe LM disease (??) seems to have best response to anti-reflux medications
RefluxRefluxFrom the perspective of a simple pediatrician:
All babies have GER (90%++ spit up)
GERD is a a concern in babies that have poor weight gain, refusal to feed, persistent crying
None of the medications we routinely use prevent reflux
Merely control acid secretion
AAP advocating for increasing lifestyle modifications before trials of medications
IJP --LaryngomalaciaIJP --LaryngomalaciaEstimated that 65-100% of babies with laryngomalacia have GERD as well
Acid reflux appears to have to have an “irritant” effect
Acid exposure within the larynx causes edema and further collapse of the laryngeal tissues
Recommend using ranitidine suspension 3mg/kg T.I.D. (9mg/kg/day)
Reflux dose in infants is 4-10mg/kg divided b.i.d. or t.i.d
Laryngomalacia and RefluxLaryngomalacia and RefluxOtolaryngology: H & N surgery, Hartl et al. 2012
Review of 27 studies (n=1295 infants) - ~60% had reflux based on varied definitions
Varied levels of evidence in the studies (no randomized control trials)
At best the authors could determine that there is a co-existence between acid reflux and laryngomalacia but evidence for a causal association is limited
Because there is widespread use of anti-reflux treatments, a RCT of anti-reflux vs. placebo is justified
Laryngomalacia and RefluxLaryngomalacia and Reflux
Arch Dis Child 2012 -- Apps et al.
Looked at the same question - does anti-reflux therapy improve symptoms in infants with LM??
Reviewed 13 case series - overall poor evidence for treating with anti-reflux medications (biased by patient selection, comparison groups and many subjective measures)
Case #3Case #3Follow up with me ~4 week after both visits
Parents think I’m a rocket scientist!!!!
Currently on ~5 mg/kg/day of ranitidine
Parents think this is what is making the difference
Increase the dose to 9mg/kg/day
Has done really well to date
Case #4Case #45 year old male
Brought to the ER with rash on legs and 2 episodes of “dark” urine
??? Blood
Complains of pain and swelling in feet/ankles - pain with walking and some pain in wrists
Episode of ?? strep throat 2/52 ago (Tx and well since)
HSP LesionsHSP Lesions
Case #4Case #4U/A confirmed microscopic hematuria - 30-50 RBC/hpf
1+ protein present as well (?? because of blood)
Told the diagnosis - discharged on Tylenol, F/U arranged in ER clinic
Mom went home and googled the diagnosis
Also talked to a cousin who is involved in dialysis
Mom drove into the ER at 1am “to see a specialist”
Case #4Case #4Symptoms subsided over the next week
Rash was getting a lot better
Admitted to hospital with an episode of “severe” abdominal pain
Settled spontaneously over 12 hours
Seen by rheumatology -- started on prednisone
Improved a lot at this point
Henoch-Schönlein PurpuraHenoch-Schönlein PurpuraNamed for two German physicians who described this in the late 19th century
Triad of purpura (rash), abdominal pain and arthritis
Small vessel vasculitis - precipitated typically by an infectious process (viral vs bacterial)
Medications can also cause this rxn (ceftriaxone, vancomycin, ranitidine etc.)
Immune mediated complexes found on vessel wall --IgA, C3
50% (range 20-70%) will have renal involvement
HSPHSPCan have some significant complications
GI bleeding
Intussuception
Renal involvement is also a major concern
Long term -- most children do very well
Over the 1st 6 months many will have relapses but progress to recovery - recurrent triggers
95% recover without complications (maybe even higher) - Renal involvement is the major concern
Is there value in treating with steroids first?
Is there value in treating with steroids first?
Steroids help minimize the symptoms of the initial presentation
Also help suppress the immune response
So why not treat all of these patients with prenisolone or prednisone on presentation
HSP and steroidsHSP and steroidsArc Dis Child - Dudley et al 2013
Large RCT of placebo vs prednisolone in presenting HSP patients
N = 350 -- Followed for 12 months
No differences in features of renal involvement between the two groups at the end of the study
?? Future studies to look at subgroups that might benefit from earlier steroids -- i.e. more severe cases
Case #4Case #4
Has done well since
Variable urinalysis - 2 episodes of microscopic hematuria, 2 normal ones
Mother still ++ anxious
Take home messagesTake home messages
Cow’s Milk Protein Allergy
Fairly rare condition (not as often we think or as often as the symptoms may suggest)
No need to change formulas frequently
If you do, use a hypoallergenic formula
Take Home MessageTake Home Message
Laryngomalacia
No real role for ranitidine in all patients -- may be a role in patients with severe disease
HSP
Common condition in childhood (especially with certain viral causes)
No proven role for treating all patients on presentation
Questions or Comments??Questions or Comments??