Common Pediatric Conditions

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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.)



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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.)




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.)



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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.)



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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.)



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.)



RECOMMENDATION 6: Complementary and

alternative medicine (CAM) for treatment of AOM. (No

recommendations are made based on limited and

controversial data.)



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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



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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



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.

Antimicrobial use for pediatric upper respiratory infections: reported practice,

actual practice, and parental beliefs. Pediatrics 1999; 104:1251-1257.

Resources and stuff Mandel EM, Casselbrant ML, et al. Systemic steroid for chronic otitis media

with effusion in children. Pediatrics 2002; 110:1071-1080.

Sarrell EM, Cohen HA, Kahan E. Naturopathic treatment for ear pain in

children. Pediatrics 2003; 111:e574-79.

Sampson HA: Role of immediate food hypersensitivity in the pathogenesis of

atopic dermatitis. J Allergy Clin Immunol 1983;71:473.

Sampson HA, Sicherer SH. Food Allergy: Current knowledge and future

directions. Immunology Clinics of NA. 1999;19:495-517.

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Resources and stuff Baraff LJ: Management of fever without source in infants and children. Ann

Emerg Med 2000 Dec; 36(6): 602-14

Jaskiewicz JA, McCarthy CA, Richardson AC, et al: Febrile infants at low risk

for serious bacterial infection--an appraisal of the Rochester criteria and

implications for management. Febrile Infant Collaborative Study Group.

Pediatrics 1994 Sep; 94(3): 390-6

Wasserman GM, White CB: Evaluation of the necessity for hospitalization of

the febrile infant less than three months of age. Pediatr Infect Dis J 1990 Mar;

9(3): 163-9

Common Pediatric Conditions

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