Pediatric Just The Facts - part 9 pdf

Nevin HISTORICAL FEATURES • Foreign body aspiration is the second most common cause of accidental death in the home among children aged less than 5–6 years.. • Symptoms at initial presen

reduced position Close monitoring of position is

required to assure proper harness position Improper

use is associated with nerve problems and avascular

necrosis of hips

R EFERENCE

Guille J, Pizzutillo P, MacEwen G: Developmental dysplasia of

the hip from birth to six months J Am Acad Orthop Surg

• Type I: Injury occurring through the physis (i.e., growth

plate), does not extend into the metaphysis or epiphysis

• Type II: Injury extends along the physis and exits

through the metaphysis

• Type III: Injury extends along the physis and exits

through the epiphysis, these may also be intraarticular

• Type IV: Injury extending from the metaphysis across

the physis and into the epiphysis, usually intraarticular

• Type V: Crushing injury to the physis from a

com-pression force (Fig 152-1)

• Descriptive terminology

1 Torus (buckle) fracture—mild fracture with plastic

deformation of one or both cortices, minimal

dis-placement

2 Greenstick fracture—cortex under tension

frac-tures completely and the compression side

under-goes plastic deformity and remains intact

3 Physeal (growth plate) injuries—describe using

Salter-Harris classification (see above)

accord-1 Type I: Wound <1cm, minimal soft tissue injury

2 Type II: Wound >1 cm, moderate soft tissue injury

3 Type III: Extensive soft tissue injury with possibleneurovascular injury and severe wound contamina-tion

• Management

1 Advanced trauma life support (ATLS) primarysurvey first

2 Immediate IV antibiotics: First generation

cephalo-sporin for type I; add aminoglycoside for types II

and III; if “barnyard” involved add penicillin ormetronidazole

3 Tetanus prophylaxis

4 Assess and document neurovascular status

5 Sterile dressing and splinting for comfort withoutdefinitive reduction

6 Operative treatment when stable

D ISLOCATIONS OF J OINT

• Traumatic dislocation of a joint requires immediatereduction in a gentle, nontraumatic and controlledfashion

• Many joint dislocations are managed by the gency room physician Examples include nurse-maidelbow (radial head dislocation) in children andshoulder dislocations in adults being the most fre-quent

emer-• Traumatic hip dislocations should be discussed with

an orthopedic surgeon for immediate reduction, sionally requiring general anesthesia with musclerelaxation in the operating room

CHAPTER 152 • FRACTURES 509

• Compartment syndrome: A potentially devastating

con-dition in which increased pressure within a fascial

com-partment of limb causes a destructive ischemia-edema

cycle unyielding to autocompensation by the vascular

system Identification and surgical release of the

affected compartments is required Recognized by the

six Ps: pain out of proportion to physical examination

findings, increased pressure, pallor skin color,

pulse-less, paresthesias, and paresis Pain with passive stretch

is one of the earlier signs Early recognition is critical

Tight bandages or splints on an injured limb can cause

increased pressure, thus caution needs to be practiced

when attending to injured limbs There are

nontrau-matic but chronic presentations of compartment

syn-drome that can exist, such as exercise-induced

M ULTIPLE F RACTURES

• Multiply injured patients should all be assessed by a

multidisciplinary approach as outlined by ATLS

pro-tocol Once the patient is stabilized, orthopedic

injuries are assessed in the secondary survey A child

with multiple fractures is best treated with early

stabi-lization of the fractures Depending on the fracture,

surgery is required for fixation of certain fractures that

would not require fixation in an isolated injury

situa-tion Surgery may be required for better mobilization

of the patient Morbidity and mortality with multiplefractures are not increased to the same magnitude as

in adult situations

INITIAL CARE OF FRACTURES

• Examine and document the sensory, motor, and cular status of the injured extremity, including jointsabove and below the injured region

vas-• Splinting techniques

1 Initial treatment of any limb injury should include

a well-molded appropriate splint Cast padding(webril = cotton padding) is applied first in severallayers thick with extra padding to bony promi-nences (elbow, heel, ankle, and so on) A posteriormold made of plaster or prefabricated fiberglass isthen applied to splint the joints above and belowthe injured region in a neutral position It is held onwith an ace bandage It is important to roll the acebandage with mild stretch to allow for swelling and

to avoid tight compression to the limb, which cancause iatrogenic skin sores or neurovascular com-promise Neurovascular assessment must be per-formed and documented after a splint is applied to

a child (Fig 152-2)

FIG 152-2 Posterior mold splinting technique, starting with cotton padding (left), followed by

posterior mold made of plaster, and lastly an ace wrap (right) Notice the 50% overlapping of each

circumferential wrap.

COMMON PEDIATRIC FRACTURES

U PPER E XTREMITY

• Upper extremity radiographic anatomy

1 Two-thirds of occult elbow fractures present with a

posterior fat pad sign If present with clinical

symptoms it requires splinting

2 Contralateral comparison elbow radiographs are

useful for diagnosis of pediatric elbow fractures

with questionable features

3 Ossification centers appear in the following order:

a Capitellum: 1–2 years old

b Radial head: 3–4 years

c Medial epicondyle: 5–6 years

d Trochlea: 7–8 years

e Olecranon: 10 years

f Lateral epicondyle: 12 years

• The above ages are approximate ages with females

ossifying earlier than males

Clavicle Fractures

• Most are midclavicular, treated in a sling until

non-tender; exceptions to conservative management include

open fractures, neurovascular compromise, or severe

tenting of the skin

Proximal Humerus Fractures

• Excellent remodeling potential, mostly treated with a

sling or coaptation splint (long-arm posterior mold

which wraps around shoulder); rarely require surgery

Supracondylar Humerus Fracture

• Type I is undisplaced; type II displaced with posterior

cortex hinging present, varus or valgus impaction;

type III is completely displaced, no cortical contact

(Gartland classification)

• Most common elbow fracture in children and is

asso-ciated with serious neurovascular compromise in

10% May lead to compartment syndromes and later

“Volkmann ischemic contracture” (compartment

syn-drome) if not recognized Careful assessment of the

anterior interosseus nerve motor function (median

nerve branch, most commonly affected) by flexion of

interphalangeal joint of the thumb and index finger,

and also the radial and ulnar nerve sensory and motor

function Initial splinting should not flex the elbow

greater than 90° secondary to potentiating

neurovas-cular compromise

Radial Head Subluxation

• “Nursemaid’s elbow.” Peak incidence 1–3 years old,

secondary to pulling or traction on the forearm/wrist

Child presents holding elbow by the side slightly flexed

and pronated and will not supinate forearm Diagnosis

is by history and physical Radiographs are normal.Reduce radial head by applying pressure over the ante-rior radial head while flexing the elbow 90° followed byrotation of the forearm into full supination If child ismoving elbow freely, immobilization is not required

Monteggia Fractures

• Radial head dislocation and ulnar fracture Anatomicrelationship of the radial head and capitellum will line

up in all radiographic views of the elbow

Radius and Ulna Diaphyseal Fractures

• “Both-Bone Forearm Fracture.” Described by tion: distal third, middle third, or proximal third.Remodeling potential in childhood with acceptableangulation ranging from 10 to 30° depending on age.Acceptable malrotation remains controversial since it

loca-is thought that it does not remodel Long-arm ing or casting is required

splint-Distal Radius Fractures

• Most common pediatric upper extremity fracture Fall

on outstretched arm is common mechanism If tender

in supination and pronation, long-arm splinting or ing required Salter-Harris classification can be used forphyseal injuries Excellent remodeling potential

cast-L OWER E XTREMITY

Hip Fractures

• Type I: Transphyseal (distinguished from slipped ital femoral epiphysis [SCFE] by younger age) severetrauma, more displaced acute separation of the physis

cap-• Type II: Transcervical or middle portion of thefemoral neck

• Type III: Cervicotrochanteric or at the base of thefemoral neck

• Type IV: Intertrochanteric or between the greater andlesser trochanter of the proximal femur

• Avascular necrosis common in types I, II, and III andneed immediate attention and reduction

Slipped Capital Femoral Epiphysis (SCFE)

• Displacement of the femoral head epiphysis on themetaphysis in a posterior-superior direction

1 Common age is 11–13 years

2 Common in obese boys

3 Approximately 25% bilaterality

4 Etiology—multifactoral, obesity, trauma, endocrinedisorder (usually present at younger age withoutobesity)

5 Clinical presentation—hip or groin pain, kneepain, limping or unable to bear weight, trauma

6 Physical examination—limping, loss of internal tion, obligatory external rotation with hip flexion

rota-7 Radiograph—AP view shows physeal widening

and metaphyseal rarefaction Kline line (line along

CHAPTER 153 • LIMPING CHILD 511

superior neck contacts the epiphysis in a normal

hip) and the frog-leg lateral are useful

8 Classified as stable or unstable Patients with stable

slips can bear weight, and symptoms are mild and

chronic Unstable slips have an abrupt onset of pain

and patients are unable to bear weight

9 Treatment—immediate nonweightbearing followed

by appropriate surgical treatment by an orthopedic

surgeon

Diaphyseal Femur Fractures

• Transverse, oblique, spiral, comminuted

General Comments on Treatment

1 Initially requires splinting in neutral position of

comfort

2 Zero to six months can consider pavlik harness or

“soft spica.”

3 Seven months to six years old spica cast

4 Seven years or more; multiple surgical options

since unlikely casting would be tolerated

Fractures About the Knee

• Tibial spine fracture: Type I—minimally displaced,

slight anterior elevation Type II—anterior third to

50% of avulsed fragment is elevated, beaklike

appear-ance Type III—avulsed fragment completely elevated

• Sleeve fracture: Patellar fracture where the patellar

tendon avulses an osteocartilagenous fragment from

distal pole of patella; requires operative repair

Ankle Fractures in Juveniles and Adolescents

• Salter-Harris classification can describe fractures

• Juvenile Tillaux fracture: Avulsion fracture of the

anterolateral distal tibia epiphysis, vertical

Salter-Harris III fracture due to external rotation force

• Triplane ankle fracture: Coronal plane, axial plane,

and sagittal plane fracture, ages 10–16 that patterns

onset of physeal closure May require computed

tomography (CT) evaluation

Base of Fifth Metatarsal Fracture

• Proximal apophyseal growth center is frequently

mis-diagnosed as a fracture It is evident radiographically at

age 9 and unites by age 12–15 years If tender on

exam-ination, splinting with a posterior mold splint is

required

R EFERENCE

Herring JA: Fractures about the elbow, in Herring JA (ed):

Tachdjian’s Pediatric Orthopaedics Philadelphia, PA, W.B.

• May follow upper respiratory infections

• Clinically present with acute onset of hip pain, ing or refusal to bear weight, hold leg in flexed posi-tion

limp-• Usually tolerate gentle range of motion as opposed tosevere pain present with a septic joint

• May have a low-grade fever, less likely

• Occurs in males > females, average age of 6 years

• Diagnosis: Made by exclusion

• Radiographs are normal, white blood cell (WBC),erythrocyte sedimentation rate (ESR), and C-reactiveprotein (CRP) are normal to mildly elevated if respi-ratory infection also present

• Ultrasound helpful to determine joint fluid or assist inaspiration if effusion present

• Differential diagnosis: Septic arthritis, juvenile toid arthritis (JRA), fracture, Legg-Calvé-Perthes,osteomyelitis, slipped capital femoral epiphysis,leukemia, hemophilia, and sickle cell crisis

rheuma-• Treatment: Rest, nonsteroidal anti-inflammatory drug(NSAID), gait assistive devices, and observation untilpain resolves If not improving, may need to recon-sider other etiologies All symptoms should resolvewithin 2 weeks

• Four clinical factors to help differentiate from sient synovitis or other etiologies include fever his-tory, inability to bear weight, ESR ≥40 mm/hour, and

tran-a WBC of >12,000 mm3 If all the factors are present

then there is a 99% chance of septic arthritis; if three

factors are present then 93% chance

• Monitoring CRP is helpful in treatment course

• Radiographs are usually normal, take 1–2 weeks for

bone changes to be seen

• Joint aspiration required; assess Gram stain, aerobic

and anaerobic cultures, cell count with leukocyte

count; consider a serum and synovial glucose level

• Most common organisms are Staphylococcus aureus,

followed by group A streptococci, Streptococcus

pneu-moniae, and Kingella kingae In neonates group B

streptococci is important and Neisseria gonorrhoeae

in neonate and sexually active adolescents is still seen

• Initial treatment: Culture and sensitivity are completed

before any medications are administered, which includes

the blood cultures and joint aspiration Surgical

treat-ment is required After all the tests are completed empiric

coverage for culture negative is done and includes an

antistaphylococcal IV antibiotic and gram-negative

cov-erage for all neonates and adolescents Length of time of

antibiotic ranges from 3 to 6 weeks with conversion to

oral antibiotics at treating physician’s discretion

• Prognosis: Related to timing of diagnosis, delayed

diag-nosis, and treatment contributes to a poorer prognosis

LEGG-CALVÉ-PERTHES DISEASE

• Osteonecrosis (i.e., avascular necrosis) of the femoral

head with subchondral collapse; etiology is unknown

• More common in males, ages 4–8 years

• Ten percent incidence of bilaterality

• History of a limp before onset of pain

• Clinically range of motion decreases as pain increases,

loss of internal rotation is first finding, antalgic gait,

some have positive Trendelenberg sign

• Diagnosis: Radiographs of the hip If negative, bone

scan or magnetic resonance imaging (MRI)

required

• Differential diagnosis: Transient synovitis, septic

arthri-tis, juvenile rheumatoid arthriarthri-tis, fracture, osteomyeliarthri-tis,

slipped capital femoral epiphysis, leukemia,

hemo-philia, and sickle cell crisis

• Four stages of the disease: (1) Early (synovitis), (2)

fragmentation, (3) reossification, and (4) definitive

• Treatment: Refer to orthopedic surgeon

JUVENILE RHEUMATOID ARTHRITIS (JRA)

• Three main forms:

1 Pauciarticular JRA: Most common; more common

in 2–4-year-old females, females greater than males

Usually present with swollen knee (most oftenaffected), ankle, or fingers, minimal pain Seventypercent positive antinuclear antibody (ANA) andnegative rheumatoid factor (RF) A quarter mayhave iritis Length of disease usually slightly over

2 years

2 Polyarticular JRA: Five or more small and largejoint involvement in either young 1–3-year-olds oradolescent age, females greater than males

3 Systemic JRA: Present in 3–10-year-olds with febrileillness, severe myalgia, polyarthritis, erythematousmacular rash, toxic, hepatosplenomegaly, and/or occa-sionally pericarditis Length of symptoms vary andsome can be vary destructive to the joints

• Diagnosis: No definitive laboratory examination.Clinical and laboratory tests to aid in the diagnosis

• A history of 6 months of arthritis for JRA for diagnosis

• Radiographs may show osteopenia around the joints,soft tissue capsular/synovial swelling, and/or narrow-ing of joint space

• Treatment: Multispecialty team approach includingrheumatologists, ophthalmologists, orthopedists, andphysical and occupational therapists

R EFERENCES

Blyth MJ, Kincaid R, Craigen MA, Bennett GC: The changing demiology of acute and subacute haematogenous osteomyelitis

epi-in children J Bone Joepi-int Surg Br 2001;83:99–102.

Kocher MS, Zuralowski D, Kasser JR: Differentiating between septic arthritis and transient synovitis of the hip in children.

J Bone Joint Surg Am 1999;81:1662–1670.

Schneider R, Passo MH: Juvenile rheumatoid arthritis Rheum

Dis Clin North Am 2002 Aug;28(3):503–30.

Denise T Ibrahim and John F Sarwark

SCOLIOSIS

• Three main types: Idiopathic scoliosis make up 80%

of cases while congenital and neuromuscular make up15%; miscellaneous scoliosis 5%

C ONGENITAL S COLIOSIS

• Failure of formation or segmentation of the ing spine, present but not always detected at birth

develop-CHAPTER 154 • SPINE 513

• Rate of progression and severity is dependent on the

type or types of anomaly within the vertebrae

• A sporadic, not inherited condition

• Anomalies include segmented hemivertebrae, wedged

vertebrae, nonsegmented hemivertebrae unilateral or

bilateral, unilateral nonsegmented bar, and/or

nonseg-mented vertebrae

• Unsegmented bar has greatest progression potential

• Klippel-Feil syndrome: Failure of segmentation in

one or more levels in cervical vertebra

• Evaluate all systems since associated anomalies

common; i.e., other musculoskeletal anomalies,

con-genital heart anomalies, hypoplastic lungs,

genitouri-nary abnormalities

• Treatment: Depends on progression and pattern of

scoliosis, careful observation until skeletal maturity,

often require surgery at younger ages, and lesser

curves when compared to idiopathic scoliosis

N EUROMUSCULAR S COLIOSIS

• Classified as neuropathic (i.e., cerebral palsy,

spin-ocerebellar degeneration, spinal muscular atrophy) or

myopathic (i.e., arthrogryposis, muscular dystrophy,

hypotonia)

• Progressive and more severe than idiopathic scoliosis

• Long thoracolumbar curve patterns with greater

pelvic obliquity

• Assessment of pulmonary, cardiac, and nutritional

status important in management of patients

• Treatment is individualized taking into consideration

functional goals, sitting balance, and pulmonary function

I DIOPATHIC S COLIOSIS

• Subdivided according to patient age: (1) Infantile,

infancy to 3 years of age; (2) juvenile, 4–9 years of

age; and (3) adolescent, 10 years and up

• Defined as a curvature of the spine 10° or higher with

• Clinically a painless condition; if pain present,

evalu-ate for other causes and perform thorough workup

• Assessment: Evaluate skin, symmetry of shoulder,

waistline, limb lengths, rib prominence angle of trunk

rotation (ATR) on forward bend test (Adam’s forward

bend test), and neurovascular examination in

prepu-bescent girls and boys

• Most are right-sided thoracic curves Left-sided

curves may indicate other etiologies that require

fur-ther investigation

• Natural history of progression is dependent on the

degree of curvature before skeletal maturity

• Treatment: General guidelines include bracing forcurves in the range of 25–45° and surgery for curvesgreater than 50° where progression likely

SCHEUERMANN KYPHOSIS

• Increased thoracic kyphosis on standing lateral graph over 40°, wedging of the anterior vertebrae ofthree contiguous vertebrae levels exceeding 5° at eachlevel; Schmorl nodes; and radiographic finding ofirregular end plates

radio-• Peak age is midteens; male predominance

• Clinical presentation: Pain at thoracic apex; poor ture according to parents

pos-• Treatment: Mostly conservative with exercises,stretching or bracing Surgery rare and consideredwhen >75° kyphosis and/or progression

SPONDYLOLYSIS AND SPONDYLOLISTHESIS

S PONDYLOLYSIS

• Defined as a radiographic unilateral or bilateraldefect in the pars interarticularis of the posterior ele-ments of the vertebrae; 50% of patients are normal onradiographs—bone scan with single photon emissioncomputed tomography (SPECT) images Obliqueviews may show posterior spine elements resembling

a “Scottie dog.” A break at the neck indicates lolysis SPECT (bone scintography) more sensitivethan radiographs

spondy-• Most commonly L5

• A common etiology of lower back pain in juvenilesand teens

• Males have 50% greater incidence than females

• Common in athletes that undergo repetitive tension stress of the spine, i.e., gymnastics, wrestling,football linebackers, diving

hyperex-• Treatment: Mostly conservative Brace (LSO—lumbo-sacral-orthosis) for symptomatic patients fail-ing conservative management; activity modification

com-• Dysplastic: Secondary to congenital anomalies of L5and S1 articulation

• Isthmic: Most common—secondary to acquireddefect in pars interarticularis; females have higher rate

of progression of slippage with low overall rate of 5%

or less

• Unlikely to progress after skeletal maturity

• Clinically: Rarely symptomatic, back pain is most

common initial complaint Lumbar lordosis and/or

lumbosacral flattening with buttock flattening, tight

hamstrings is seen in advanced cases

• Grading system: Meyerding: Grade I—up to 25%

slippage on lateral radiograph, grade II—26–50%,

grade III—51–75%, grade IV—76–100%, and grade

V—>100% (spondyloptosis)

• Imaging: Standing posteroanterior and lateral

lum-bosacral radiographs

• Treatment: Based on severity, pain, slip grade,

skele-tal maturity for conservative vs surgical treatment

R EFERENCE

Weinstein SL: Long-term follow-up of pediatric orthopaedic

con-ditions: Natural history and outcomes of treatment J Bone

Denise T Ibrahim and John F Sarwark

NORMAL DEVELOPMENT OF LOWER EXTREMITIES

• Birth: Increased bowlegs (genu varum) and internal

tibiofemoral torsion

• Eighteen months: Start to straighten lower limbs

• Three to four years old: Increased knock-knees (genu

valgum)

• Seven years old: Straighten knock-knees to a normal

average of 7° valgum (femoraltibial angle)

GENU VALGUM (KNOCK-KNEES)/

GENU VARUM (BOWLEGS)

• Important to understand normal development of lower

extremity alignment to determine if physiologic type

is present vs pathologic type

• If suspicious of pathologic limb alignment oneassesses age of onset compared to normal develop-ment, progression of deformity (i.e., Blount disease)diet (i.e., Rickets), trauma (i.e., asymmetric physealclosure), growth percentile (i.e., skeletal dysplasia),and congenital anomalies

• Examination: Assess gait, limb symmetry, lar distance of knee for bowlegs or medial malleolardistance for knock-knees to document progression,and joint laxity Radiographs may indicate ricketswhen physeal changes or other metabolic causes areseen When severe or asymmetric, refer to pediatricorthopedic surgeon

intercondy-IN-TOEING/OUT-TOEING

• Most common pediatric orthopedic concern of parentsfor the toddler

• Most are physiologic rather than pathologic

• Femoral internal rotation (anteversion) or externalrotation (retroversion), tibial internal rotation or exter-nal rotation, or foot development (i.e., metatarsaladductus, clubfoot)

• Important to accept 2 SD from normal, in accordancewith age, in any direction before considering align-ment abnormal

• Normally, femoral internal rotation decreases withage to near 10° at maturity and tibial external rotationincreases with age as it is often internally rotated(i.e., appearance of in-toeing) foot progression angleslowly externally rotates during development up untilages 11–14 years

• Examination of the entire extremity including sional alignment is essential

com-4 Check hip rotation with child in prone position.Knees flexed 90° and rotate femur internally andexternally (Fig 155-1) In a younger child there ismore internal rotation than external rotation of thehip

5 Check tibia torsion in prone position, thighs areparallel to each other with knees flexed and thelong axis of the hindfoot and the long axis of thethigh form the thigh-foot angle (Fig 155-2) In-toeing is most notable after child begins to walk

CHAPTER 155 • PHYSIOLOGIC DEVELOPMENT OF LOWER EXTREMITY ALIGNMENT 515

FIG 155-2 Thigh foot angle to assess tibia rotation.

6 In-toeing is a common concern of parents Education,reassurance, and observation are advised Surgery is

rarely needed.

a Infants: Out-toeing commonly seen withinfants secondary to external rotation intrauter-ine position of the hips Resolves with time andconsidered normal Often overlooked or misdi-agnosed

b Infants: In-toeing may be secondary to ing great toe or adducted toe This is a hyperac-tive adductor hallucis muscle as stancepositioning begins in early toddler gait Usuallyresolves spontaneously Reassurance is recom-mended

search-c Toddlers: In-toeing is a common complaint at 2years of age due to internal tibial torsion.Improves without treatment Bracing has noproven benefit

d Child: In-toeing secondary to femoral sion at age greater than 3 years Excessive inter-nal rotation of hips compared to externalrotation is seen on examination If severe, ortho-pedic referral required

antever-PES PLANUS (FLATFOOT)

• Infant: Lack arch secondary to excess subcutaneous

fat and normal ligamentous laxity which improves

once walking

• No cause of disability

• Often hereditary

• Assessment: While standing foot appears flat, when

standing on toes arch reappears showing it is flexible

and not a fixed deformity

• If fixed and not flexible on examination may need

fur-ther workup

• Arch supports not required if asymptomatic

• Flatfeet with tight heel cord Assess dorsiflexion of

foot and ankle with knee flexed and extended to

determine whether contracture of soleus or

gastroc-soleus complex, respectively are responsible for

flatfeet

P AINFUL OR R IGID F LATFEET

• Consider referral to orthopedist if symptomatic or

rigid to rule out pathology

1 Congenital anomalies include skewfoot or vertical

talus, tarsal coalition (failure of separation of tarsal

bones)

2 Most of the pathologic conditions are treated by

conservative measures such as observation,

inserts or casting, and physical therapy Surgery

may be indicated for those failing conservative

treatment

M ISCELLANEOUS F OOT D ISORDERS

• Talipes equinovarus (clubfoot): Congenital deformity

of the foot with equinus, varus, adduction of forefoot,

and internal rotation deformity Refer to pediatric

orthopedist

• Etiology: Extrinsic (molded) or intrinsic (genetic)

Varying degrees of severity Can be associated with

other conditions, i.e., arthrogryposis, torticollis,

syn-dromes, and so on

• Treatment: Goal is to correct deformity as soon after

birth as possible with initial serial casting Casting

techniques include the Ponseti (Iowa) method or

Demeglio (French) method Surgical treatment may

be required in cases where casting techniques

incom-pletely correct the problem

R EFERENCE

Tachdjian MO: The foot and leg In Tachdjian MO (ed): Pediatric

Orthopaedics, 2nd ed Philadelphia, W.B Saunders, 1990.

p 2810.

Denise T Ibrahim and John F Sarwark

PREPARTICIPATION PHYSICAL EXAMINATION (PPE)

• Goal: Detect conditions that may predispose athlete toinjury or life-threatening risk

• Timing: Four to six weeks before the season begins andrepeated before each level of competition (i.e., junior

high, high school, and college) Does not replace the

yearly health supervision examination recommended bythe American Academy of Pediatrics (www.aap.org)

• History: Parent’s input important, and questions tively screen for problems that may lead to suddendeath The PPE task force forms and questions can be

effec-found in the Preparticipation Physical Examination

by Smith DM, Kovan JR, Rich BSE, and Tanner SMand published by Mcgraw-Hill

• Physical examination: Identify those who may needfurther evaluation or intervention

1 Cardiovascular examination: Peripheral pulses,heart murmur, and blood pressure

2 Musculoskeletal examination: Focus on previousinjured areas or symptomatic areas Assess flexi-bility, range of motion, symmetry, atrophy orswelling, neurovascular status, joint stability, andnutritional status

3 Labs: None found to be effective in assymptomaticpatients and none required unless specified byindividual team or organization

4 Clearance—Again refer to the Preparticipation

Physical Examination text for the most current

rec-ommendations and the Proceedings of the 26th

Bethesda Conference on cardiovascular

abnormal-ities for cardiac condition clearance

5 When families and/or patients disagree with ommendation, it is important to have a signed doc-ument from the parents acknowledging thediscussion and recommendations

rec-HEAT-AND-COLD RELATED ILLNESSES

• Thermoregulation differs in children at extremes oftemperatures secondary to their surface area to massratio being higher than adults, less blood volume,sweat gland diminished sensitivity until teens andacclimatization

• Heat illnesses

1 Exercise induced cramps: Produced by prolongedvigorous exercise, extreme sweating, fluid, and

CHAPTER 156 • SPORTS MEDICINE 517

electrolyte shifts If recurrent episodes, consider

electrolyte evaluation and sodium food

supplemen-tation

2 Syncope: Loss of consciousness with core body

temperature normal to slightly elevated after

activity stops secondary to skin vasodilation,

hypovolemia, and hypoperfusion Treatment:

Move to cool location, rectal temperature to rule

out heat stroke, check for injuries, and support

with fluids

3 Exhaustion: Elevated core temperature rectally of

100.4–104°F causing mild confusion, dizziness,

headache, nausea, chills, and collapse Treatment

includes cooling, monitor rectal temperature, fluid

replacement with cool liquids

4 Heatstroke: Medical emergency, imbalance of heat

load with heat dissipation system Core

tempera-ture rectally is >104°F with abnormal mental status

and tachycardia Treatment: Ambulance transport

to hospital, fans, cool mist sprays, and immediate

cool IV hydration enroute to ER, and sequential

rectal temperatures Rule out arrhythmias with any

collapse

• Cold illnesses

1 Hypothermia: Core temperature decrease in mild

cases 93–97°F, moderate is 86–93°F (stiffness,

slow respirations, confusion, lethargy, decreased

heart rate), and severe is <86°F (weak pulse,

arrhythmias, coma) Treatment includes controlled

warming, locally with mild cases and moderate

and severe cases in hospital Start with removing

wet clothes; apply warm blankets and radiant heat

No hot objects directly on skin

2 Frostbite: Treatment: Gentle care of skin, no

rub-bing, and water temperature of 100–112°F to

rewarm May require surgical debridement

OVERUSE INJURIES

• Pediatric population experience stress fractures or

apophysitis Treatment requires rest, splinting,

and/or activity modification If cessation of sport is

required for healing it is important to continue

exer-cise program

TRAINING THE YOUNG

• Important to increase adaptive changes to enhance

performance

• Many questions are unanswered as to how much sport

or training is too much The physical and

develop-mental stresses to a growing child are different than in

an adult

• Understand the individual child’s abilities and ponse to stresses Intense training programs as ex-pected of an adult are inappropriate in the child

res-• Strength training: Supervised proper resistive ing program Modest increase in strength and tone inprepubescent children but not muscle bulk isexpected

train-CEREBRAL CONCUSSIONS

• Transient traumatic disruption of cognitive function

• Signs and symptoms: Headache, sleep disturbance,confusion, dizziness, nausea, loss of balance, loss ofconsciousness, amnesia, emesis, tinnitus

• Management: Whether conscious or unconscious ruleout cervical spine trauma Emergency care if uncon-scious If conscious and ambulating, assess cognitionand physical function If symptoms last more than

15 minutes, no return to play that day

CHEST INJURIES

• Skeletal injuries most commonly include rib fractures,clavicle fractures, sternoclavicular dislocations, orphyseal disruption

• Life-threatening injuries include pneumothorax(hemo- and tension), cardiac contusion, pericardialtamponade, and pulmonary contusion

SPECIAL OLYMPICS SCREENING

• Special screening in Down syndrome children: Checkfor atlantoaxial instability detected or lateral radi-ographs of the cervical spine in flexion and extension.Compare the atlantodens interval (ADI) Normal ADI

is less than 2.5 mm

FEMALE ATHLETE

• There is a dramatic increase in female sport tion requiring an understanding of unique medicalconcerns of the female athlete

participa-• “Terrible female athlete triad”: Eating disorder, orrhea, and osteoporosis

amen-• Severely delayed or absent menses is a concern giventhe adverse affects it may have on bone mineral den-sity Counseling and treatment is advised

• Eating disorders: Higher risk involving participants of

gymnastics, diving, figure skating, dance, and

swim-ming Early identification and a multidisciplinary

approach of counseling that include nutritional and

psychologic approaches

• Iron deficiency: Common condition in female

ath-letes, especially in long-distance runners, resulting in

anemia

R EFERENCE

Barrett JR, Kuhlman GS, Stanitski CL, Small E: The pation physical examination, in Sullivan JA, Anderson SJ

prepartici-(eds): Care of the Young Athlete Rosemont, IL, American

Academy of Orthopaedic Surgeons and American Academy of Pediatrics, 2000 pp 46–55.

157 FOREIGN BODY

ASPIRATION

Mary A Nevin

HISTORICAL FEATURES

• Foreign body aspiration is the second most common

cause of accidental death in the home among children

aged less than 5–6 years

• Eighty-five percent of occurrences in children less than

3 years Peak incidence is in those children aged 1–2

years Boys are more likely to be affected than girls

• Organic material such as nuts, hot dogs, grapes, and

hard candy are most commonly aspirated by children

• Various inorganic items such as coins, small metal

and plastic pieces, marbles, batteries, and buttons may

also be aspirated

• Latex balloons are one of the leading causes of toy

related choking deaths This item is also extremely

difficult to remove from the airway with standard

rescue techniques such as the Heimlich maneuver

• Children with neurologic disease or developmental

delays are at increased risk for choking-related

mor-bidity and mortality

• Incidence is decreasing in recent years, perhaps due to

federal safety legislation and increased awareness

CLINICAL PRESENTATION

• Clinical history and a high level of suspicion are of

inestimable importance in the evaluation of foreign

body aspiration

• Aspirated foreign bodies can be found in any segment

of the tracheobronchial tree The location in which a

foreign body lodges is determined by the size andshape of the aspirated object as well as by the force ofinspiration

• Foreign bodies that lodge in the larynx are associatedwith acute respiratory arrest and a high mortality rate

• Most foreign bodies are found in the mainstembronchi or distal trachea but small objects can befound in more peripheral locations The right main-stem bronchus is affected more commonly than theleft owing to the angle of airway take off

• Tracheal foreign bodies are more common in the ting of tracheomalacia, tracheal narrowing from priorsurgery, or weakened pulmonary function (i.e., neuro-muscular disease)

set-• In the absence of the need for emergent medical agement (i.e laryngeal FB), a careful history should beobtained The classic history of a choking episodewhile eating or playing or that of a choking episode fol-lowed by a violent coughing spasm should be sought

man-• It should be emphasized that the absence of such a sic history does not exclude the presence of a foreignbody In fact, the characteristic initial history is absent

clas-in up to 50–60% of cases

• The sudden onset of pulmonary symptomatology in achild should always suggest a possible foreign body inthe airway The presence of chronic cough or wheezewithout clear etiology should also suggest the diagnosis

• Clinical manifestations and symptoms of foreignbody aspiration are dependent on the size of the aspi-rated object and its composition as well as the location

of the aspirated object, the degree of airway mise/obstruction and the length of time elapsed sincethe aspiration event

compro-• Symptoms may occur within hours of the aspirationevent or up to weeks to months later

• Common symptoms with acute presentation includewheezing, choking, coughing, inspiratory stridor,hoarseness and dyspnea

Section 19

RESPIRATORY DISORDERS

519

Susanna A McColley, Section Editor

Copyright © 2005 by The McGraw-Hill Companies, Inc Click here for terms of use.

• A paroxysmal cough will often immediately follow an

aspiration event Thereafter, there will often be a period

during which respiratory symptoms abate This is due

to an adaptation response in the respiratory mucosa

This lag period may be a source of unfounded

reassur-ance The return of the cough (which may prompt

clin-ical presentation) is often due to accumulation of

secretions, infection or atelectasis

• Symptoms at initial presentation may represent a

complication of foreign body aspiration such as

chronic cough, recurrent wheezing, persistent fever

due to persistent/recurrent pneumonia, hemoptysis,

and bronchiectasis

• Symptoms of a foreign body in the upper airway may

be mimicked by a foreign body in the esophagus

which creates pressure on the posterior trachea

• Differential diagnosis includes croup, asthma,

atypi-cal asthma, bronchiolitis, laryngitis, pharyngitis, and

angioneurotic edema

PHYSICAL EXAMINATION FINDINGS

• Physical findings are based on the location of the

obstructed airway as well as whether that obstruction

is partial or complete

• Physical findings may include cough, wheeze and

rhonchi or decreased/absent breath sounds over the

affected lung segment This constellation of symptoms

is only present in about one-third of patients presenting

with foreign body aspiration However, nearly twice as

many will have one or more of these findings

• Children may be comfortable with only subtle

respira-tory symptoms or they may show variable degrees of

respiratory compromise including increased work of

breathing, tachypnea, stridor, retractions and cyanosis

• Changes in symptoms and severity of respiratory

dis-tress may be seen secondary to changes in position of

the foreign object and local edema

• A careful exam may predict the location of a foreign

body A prolonged expiratory phase or expiratory

wheeze is suggestive of bronchial obstruction Stridor

(inspiratory or biphasic) and hoarseness (or frank

aphonia) is more suggestive of a proximal tracheal or

laryngeal obstruction

• In many cases, physical findings are subtle In fact,

the physical examination can be entirely normal

CLINICAL EVALUATION

• In all situations suggestive of foreign body aspiration,

neck and chest radiographs should be obtained

• 5–10% of foreign bodies are radioopaque In these

cases, the diagnosis is easily confirmed with a plain

radiograph

• The majority of foreign bodies are radiolucent andabnormalities seen on radiographs are secondary toairway obstruction (i.e air trapping)

• Inspiratory and expiratory films should be obtained.The classic finding is obstructive emphysema in theaffected lung segment on an expiratory radiograph

• Partial airway obstruction leads to progressive air ping through a ball-valve effect Obstructive emphysema

trap-is the radiographic correlate Shift of the mediastinumaway from the affected hemithorax may be seen

• In the case of complete bronchial obstruction, tasis is the result In severe cases, a shift of the medi-astinum may occur toward the affected hemithorax

atelec-• Lateral decubitus views of the chest and fluoroscopyare other studies that may demonstrate unilateralhyperinflation Whereas plain chest films may be neg-ative in up to 25% of aspiration cases, fluoroscopy is

a more sensitive, yet noninvasive option

• When a foreign body remains in the airway, late ographic findings may represent complications whichinclude post-obstructive atelectasis, emphysema ofthe contralateral lung, pneumonia, parapneumoniceffusion, pneumothorax, pneumomediastinum, medi-astinal shift, pulmonary abscess and bronchiectasis

radi-• Prolonged presence of a foreign body with secondaryobstruction, air trapping and inflammation are impor-tant precursors in the development of chronicbronchiectasis

• Final diagnosis of foreign body aspiration or sion thereof must be by direct laryngoscopy and bron-choscopy

emer-• Emergent maneuvers designed to treat acute andsevere/complete upper airway obstruction includeabdominal thrusts (Heimlich maneuver) in childrenone year and older, back blows and chest thrusts forchildren less than one year of age and blind fingersweeps of the oropharynx (only for children eightyears of age and older) Emergent guidelines and spe-cific resuscitation protocols should be further andcompletely accessed through the American HeartAssociation and the American Academy of Pediatrics

• Acute airway obstruction in a conscious child may beindicated by a sudden onset of tachypnea, dyspnea,cyanosis or an inability to cough or talk An anxious

CHAPTER 158 • BRONCHITIS AND BRONCHIOLITIS 521

appearance may also herald an acute worsening of

res-piratory status

• Medical therapies, including inhalation of

bron-chodilators and chest physiotherapy, are

contraindi-cated secondary to a significant risk for foreign body

migration and cardiopulmonary arrest

• Rigid bronchoscopy is the standard of care for the

evaluation, localization, management, and removal of

tracheal and bronchial foreign bodies in the pediatric

population

• Following endoscopic removal of a foreign body,

symptoms due to airway edema and pulmonary

parenchymal changes arising from the presence of the

foreign object may take several days to abate

• Postoperative management may include humidification

of inspired air, supplemental oxygen, steroids, chest

physiotherapy, or antibiotics in complicated cases

B IBLIOGRAPHY

Cotton, RT Foreign body aspiration In: Chernig and Boat (eds.),

Kendig’s Disorders of the Respiratory Tract in Children, 6th ed.

Philadelphia: W.B Saunders, 1998 601–607, 822, 983,

1518–1520, 1475–1477.

Fausnight T, et al Determining the cause of recurrent wheezing.

J Respir Dis 2002;126–131.

Loin, MI Foreign bodies In: McMillan et al, Oski’s Pediatrics:

Principles and Practice, 3rd ed Philadelphia: Lippincott

Williams & Wilkins, 1999 639–640, 570–571, 1273–1275,

• Acute bronchitis (actually tracheobronchitis) is a

tran-sient inflammation of the trachea and major bronchi

manifested primarily by cough It is usually caused by

a viral infection (respiratory syncytial virus [RSV],

parainfluenza, influenza, adenovirus, and rhinovirus)

and resolves without therapy within 3 weeks

Occa-sionally it is caused by bacteria and chemical exposure

The diagnosis is usually a clinical one and laboratory

tests are generally unnecessary

• Chronic bronchitis in adults is defined as a productivecough for 3 months a year over 2 consecutive years.The definition in children is less clear Persistentsigns and symptoms of tracheobronchitis for morethan 3 weeks should initiate an attempt to identify anunderlying disorder The differential diagnosis shouldinclude asthma, cystic fibrosis, aspiration, immuno-deficiency, retained foreign body, dynamic or extrinsicairway compression, inhalation injury, tuberculosis,and primary ciliary dyskinesia

BRONCHIOLITIS

BACKGROUND

• Bronchiolitis is a common lower respiratory tract dition in infants and is the most common cause forhospitalization among infants <6 months of age

con-• Although several viruses can cause bronchiolitis, themost common etiology is RSV Other viruses that cancause bronchiolitis include parainfluenza, metapneu-movirus, influenza, and adenovirus

• Almost all children are infected with RSV at leastonce by the age of 2 years and reinfection throughoutlife is common

• Most healthy infants with RSV do not require talization and those that do are usually dischargedwithin 5 days

hospi-• Several conditions can increase the risk of severe orfatal RSV bronchiolitis Infants and young children athigh risk for these complications include the following:

1 Cyanotic or complex congenital heart disease

2 Chronic lung disease due to prematurity

3 Prematurity, low birth weight

4 Immunodeficiency disease or immunosuppressivetherapy

5 Other chronic pulmonary disorders, includingcystic fibrosis

• RSV mortality in hospitalized high-risk childrenreportedly ranges from 3 to 4%

• Temperate zone outbreaks of RSV generally occur inwinter or spring

• Peak incidence of RSV occurs between 2 and 3 months

of age (whereas peak incidence of parainfluenza is

later at 10.6 months of age)

• Infection is associated with increased goblet cell

mucus production and desquamation of epithelial cells

that result in the plugs responsible for air trapping and

4 Apnea, especially in young infants

• In more severe cases, additional symptoms include the

1 Rhinorrhea is usually present

2 Otitis media may be seen

3 Chest examination may reveal retractions in

moderate-to-severe cases

4 Bilateral, diffuse, crackles are common

5 Wheezing may be present

6 Signs of central nervous system (CNS) depression

may be seen with impending respiratory failure

DIAGNOSTIC TESTS

• Pulse oximetry should be performed in infants with

RSV who have increased work of breathing, poor

feeding, pallor/cyanosis, or irritability

• Nasopharyngeal secretions may be tested for RSV

using a rapid antigen test (generally 80–90%

sensi-tive) This is especially useful in hospital settings, for

infection control and epidemiologic purposes Viral

culture requires 3–5 days with greatly varying results

depending on the laboratory

• The chest radiograph may show hyperinflation,

non-specific increases in perihilar bronchial markings, or

atelectasis Routine chest radiography is not necessary

in mildly to moderately ill infants and children with

typical bronchiolitis

• An arterial blood gas should be performed in severely

ill infants and in those with progressive signs and

• Excessive secretion of antidiuretic hormone in RSVinfection has been reported in infants with severedisease

TREATMENT

• Treatment of RSV bronchiolitis is primarily supportive

• Oxygen should be administered to achieve SpO2>92%

• Dehydration can occur when fever and tachypneaincrease fluid demands and dyspnea and tachypnealimit intake Parenteral fluids are often necessary.Attention to nutrition with consideration of nasogas-tric tube feeding for infants with inadequate oralintake or who are moderately to severely ill

• Mechanical ventilation may be necessary for infantswho develop apnea or respiratory failure (PaCO2>55torr and PaO2 <70 torr while receiving 60% supple-mental O2)

• Studies of bronchodilators generally show no benefitunless there is underlying bronchial hyperreactivityresulting in bronchospasm

• There is no role for chest physiotherapy for moderate bronchiolitis

mild-to-• Theophylline has not been shown to alter the course

of bronchiolitis in infants

• Early studies of nebulized racemic epinephrineappeared promising; however, a large, double-blind,placebo-controlled multicenter study showed noreduction in the length of hospital stay

• Studies of corticosteroids generally show no benefitalthough a recent metaanalysis reported some benefit

in those with severe symptoms or requiring cal ventilation

mechani-• Exogenous surfactant may have some benefit in onepilot study but further investigation is necessary

• Heliox may have some benefit in overcoming airwayresistance but only for patients requiring 45% or lesssupplemental O2

• Antimicrobials are rarely indicated

FOLLOW-UP

• Viral shedding up usually 3–8 days although can last

as long as 3–4 weeks

CHAPTER 159 • BRONCHOPULMONARY DYSPLASIA 523

• Reports of greater than expected incidence of asthma

into late childhood in those with RSV bronchiolitis

his-tory Both genetic and environmental factors determine

the type of immune response to RSV infection It has

been proposed that this immune response may affect

the development of control mechanisms involved in the

regulation of airway tone

PREVENTION

• No vaccine is currently available

• Prophylaxis with Palivizumab, a humanized

mono-clonal antibody directed against RSV, may reduce

hospital length of stay, ICU admissions, and ICU

length of stay in high-risk populations

• Current guidelines for Palivizumab administration

include the following:

1 Infants ≤2 years old with chronic lung disease,

con-genital heart disease, or other serious conditions

that compromise pulmonary or immune function

2 Infants without chronic lung disease or congenital

heart disease:

a Premature infants ≤28 weeks if born ≤12 months

before RSV season

b Premature infants 28–32 weeks if born ≤6 months

before start of RSV season

c Premature infants 32–35 weeks if born <6 months

before the start of RSV season and with

addi-tional risk factors

• The use of Palivizumab in other respiratory diseases,

such as cystic fibrosis and chronic respiratory failure

(for reasons other than those noted above), has not

been adequately studied Many practitioners

recom-mend Palivizumab for these populations because of

the high risk for morbidity and mortality, but practice

remains variable

• Palivizumab is administered once per month with the

first dose generally given at the beginning of

November and last dose at the beginning of March,

which will provide protection until April

B IBLIOGRAPHY

American Academy of Pediatrics Respiratory syncytial virus In:

Pickering LK (ed.), Red Book: 2003 Report of the Committee

on Infectious Diseases, 26th ed Elk Grove Village, IL:

American Academy of Pediatrics, 2003, pp 523–528.

Loughlin GU Bronchitis In: Chernick V, Boat T (eds.), Kendig’s

Disorders of the Respiratory Tract in Children, 6th ed.

Philadelphia, PA, W.B Saunders, 1998, pp 461–472.

Jafri HS Treatment of respiratory syncytial virus: antiviral

ther-apies Pediatr Infect Dis J 2003;22:S89–S93.

Wainwright C, et al A multicenter, randomized, double-blind, controlled trail of nebulized epinephrine in infants with acute

bronchiolitis N Engl J Med 2003;349:27–35.

Weisman LE Populations at risk for developing respiratory cytial virus and risk factors for respiratory syncytial virus

syn-severity: infants with predisposing conditions Pediatr Infect

Dis J 2003;22:S33–S39.

Welliver RC Respiratory syncytial virus and other respiratory

viruses Pediatr Infect Dis J 2003;22:S6–S12.

of the newborn

• Characteristic radiographic findings are the following:

1 Stage I: Bilateral hazy infiltrates characteristic of piratory distress syndrome (RDS) of the newborn

res-2 Stage II: Diffuse opacification

3 Stage III: Interstitial emphysema

4 Stage IV: Cystic radiolucent areas, hyperinflation,and patchy fibrosis present after 28 days demon-strating chronic pulmonary findings

• Requirement of supplemental oxygen past 28 days orbeyond 35 weeks gestation

RISK FACTORS FOR DEVELOPMENT OF BPD

• Birth weight: One-third of surviving babies bornbet-ween 500 and 1000 g and 10% of babies above

1000 g will develop bronchopulmonary dysplasia(BPD)

• Coarse crackles increase especially during upper

res-piratory tract infections (URI)

• Fine crackles are variable and occur in patients prone

• Associated findings due to chronic respiratory

insuffi-ciency may include failure to gain weight due to high

caloric expenditure and cor pulmonale

• Pulmonary exacerbations are frequently triggered by

URIs and are characterized by increased work of

breath-ing above baseline which may quickly result in acute

respiratory failure and should be identified promptly

TREATMENT

M AINTENANCE T HERAPY

• Supplemental oxygen to maintain hemoglobin

satura-tion above 90% Tapering of oxygen therapy starts

during wakeful periods When saturations are

accept-able and staccept-able, tapering at night can be aided by

pro-longed oximetry monitoring prior to the therapy being

discontinued

• Diuretic therapy is initiated to decrease lung water

and lower airflow resistance in patients prone to fluid

overload Diuretic therapy is generally maintained

until supplemental oxygen can be discontinued

Electrolyte balance must be monitored especially with

dosage changes

• Inhaled beta-agonist bronchodilators are used to

relieve work of breathing associated with wheezing

and air trapping Beta-agonists may as well improve

mobility of pulmonary secretions

• Inhaled anticholinergic bronchodilators are

consid-ered in patients with significant large airway malacia

that do not respond or worsen with the administration

of beta-agonists

• The use of inhaled glucocorticoid therapy remains

con-troversial Maintenance therapy may reduce the need

for repeated courses of oral steroids during

exacerba-tions Close monitoring of glucocorticoid side effects is

necessary with continuation of prolonged therapy

• RSV immunoprophylaxis is provided based on AAP

guidelines dictated by severity of lung disease,

gesta-tional age at birth, and chronologic age

E XACERBATION T HERAPY

• Many patients with chronic respiratory insufficiency

will quickly decompensate to respiratory failure

during exacerbations

• Prevention of illness from viral pathogens is crucial.Frequent hand washing is necessary for all householdcontacts, especially prior to handling

• Patients usually require an increase of supplementaloxygen to provide adequate saturations above 90%

• Inhaled bronchodilator therapy is increased based on ical response of improved tachypnea and air exchange

clin-• Diuretics are optimized for patients with evidence ofpulmonary edema

• Systemic steroid use is not standardized but frequentlyconsidered

• There is increased risk for pulmonary aspiration andesophageal reflux with aspiration during an exacerba-tion; appropriate antireflux and aspiration precautionsfor the patient should be observed

• With frequent exacerbations, a secondary diagnosis may bepresent such as asthma, cystic fibrosis, immunodeficiencystates, and chronic pulmonary aspiration syndromes

Silva-of neonatal chronic lung disease J Pediatr 1995;126: 605–610.

Stevenson DK, Wright LL, Lemons JA, Oh W, Korones SB, Papile

L, Bauer CR, Stoll BJ, Tyson JE, Shankaran S, Fanaroff AA, Donovan EF, Ehrenkranz FA, Verter J Very low birth weight out- comes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through

December 1994 Am J Obstet Gynecol 1998;179:1632– 1639.

DISEASE

Corinda M Hankins

DEFINITION

• Interstitial lung disease (ILD) describes inflammation

of the pulmonary interstitial space which consists of

CHAPTER 160 • INTERSTITIAL LUNG DISEASE 525

alveolar walls and perialveolar tissues There are

con-nective tissue components, mesenchymal cells, and

inflammatory cells in the interstitium

• This inflammation can begin as a normal response to

infection or irritant agent Persistent inflammation can

cause disruption of the alveolar units which can lead

to poor gas exchange and eventually restrictive lung

disease

CLINICAL PRESENTATION

• Onset is usually insidious and presentation is variable

• The most common symptoms are dry cough, tachypnea,

dyspnea, and exercise limitation

• Patients may present with frequent recurrent

respira-tory infections

• There may be evidence of weight loss or growth failure

• The physical examination may show tachypnea,

retractions, and basilar crackles heard late in

inspira-tion In severe cases, cyanosis and clubbing may be

present

• There are no definitive clinical criteria for the

diagno-sis of interstitial lung disease

ETIOLOGY AND CLASSIFICATION

• ILD is rare in children

• There are many types of interstitial disorders of both

known and unknown etiology (Fan and Langton, 1998)

• In known disorders there is activation of inflammatory

cells in the interstitium secondary to direct injury or in

response to injury

1 Infectious etiologies should be separated into

chronic infections in both immunocompetent

and immunocompromised hosts Most common

etiologies are viral (e.g., adenovirus, influenza,

cyto-megalovirus [CMV], human immunodeficiency

virus [HIV]), bacterial (e.g., Chlamydia,

Myco-plasma, Mycobacterial, Pertussis), and fungal (e.g.,

Aspergillosis, Pneumocystis).

2 Aspiration syndromes secondary to swallowing

dys-function, tracheoesophageal fistula, or

gastro-esphageal reflux disease can lead to chronic diffuse

infiltrates

3 Environmental inhalants (e.g., organic dusts) or

toxins can lead to an immunologic response in the

lung such as hypersensitivity pneumonitis Other

toxins include some drugs, radiation, or chemical

fumes

4 Some patients have a known underlying systemic

condition that can predispose to ILD such as

meta-bolic storage diseases or lymphoproliferative

dis-orders Interstitial lung disease may be associatedwith systemic disorders such as autoimmune disease,collagen vascular disease, pulmonary vasculitides(e.g., telangiectasia), neurocutaneous syndromes,and malignancies

• Interstitial lung diseases of unknown etiology wereoriginally described in adults on histopathologic basis(Fan and Langton, 1998) These classic forms are rare

in childhood They include usual interstitial monitis (UIP), desquamative interstitial pneumonitis(DIP), lymphocytic interstitial pneumonitis (LIP),bronchiolitis obliterans with organizing pneumonia(BOOP), pulmonary hemosiderosis, sarcoidosis, andalveolar proteinosis

pneu-1 UIP is the most common form in adults There isinflammation and injury in patchy distribution that

is usually associated with some fibrosis on logic specimen

patho-2 DIP is a diffuse histologic process of hyperplasia ofalveolar epithelial cells and a large number ofmacrophages in the airspaces (Fan and Langton,1998)

3 LIP is most commonly seen in children This entityappears to be more lymphoproliferative in naturewith diffuse infiltrates of mature lymphocytes LIP ismost often seen in immunodeficiency states andautoimmune disorders such as acquired immunode-ficiency syndrome (AIDS) (Fan and Langton, 1998)

DIAGNOSTIC EVALUATION

HISTORY AND PHYSICAL EXAMINATION

• A careful history of prenatal events, growth and opment, environmental exposures, and other possibleunderlying conditions should be taken, with a focus

devel-on the devel-onset, duratidevel-on, and progressidevel-on of respiratorysymptoms

• A thorough review of systems will help assess tious or immunologic disorders

infec-• Dry cough is typical and may be severe Tachypnea,retractions, basilar crackles, cyanosis, and clubbingmay be present on physical examination

STUDIES

• Routine studies to assess for most common etiologiesinclude a complete blood count (CBC) with differen-tial, erythrocyte sedimentation rate (ESR), viral cul-tures, bacterial cultures, and fungal cultures as well as

HIV serology and purified protein derivative of

tuber-culin (PPD) A barium esophagram, videofluoroscopic

swallowing study, and pH probe are initial studies to

evaluate for aspiration syndromes

• Further assessment of associated disorders includes

immunologic workup (e.g., qualitative

immunoglobu-lins, T- and B-cell function, antibody function,

hyper-sensitivity testing, and autoantibodies)

• Consider cardiac evaluation for cor pulmonale

PULMONARY FUNCTION TESTING USUALLY

IN CHILDREN OVER 6

• Pulmonary function testing may show restrictive lung

disease with reduced FVC and FEV1, normal

FEV1/FVC ratio and reduced total lung capacity (TLC)

• Carbon monoxide diffusion capacity is often reduced

• Oxygen saturation is reduced in more severe disease

• Consider exercise tolerance testing to assess for

exercise-related hypoxemia

DIAGNOSTIC IMAGING

• Chest x-ray (CXR) classically shows diffuse infiltrates

described as interstitial, alveolar, or mixed interstitial/

alveolar CXR can be normal in the setting of early

ILD

• Chest-computed tomography with high-resolution

cuts can be very helpful in detecting early alveolar

thickening associated with interstitial lung disease It

can also provide detail about the distribution of

infil-trates which can aid in determination of specific site

for bronchoalveolar lavage or biopsy

BRONCHOALVEOLAR LAVAGE

• Bronchoalveolar lavage is a good tool for assessment of

infection, aspiration (lipid laden macrophages), and

pul-monary hemorrhage (hemosiderin laden macrophages)

• BAL has limited ability to determine the etiology of ILD

TRANSBRONCHIAL BIOPSY

• This method is used in the monitoring of lung

trans-plant patients for infection and rejection, but its

use-fulness in the assessment of ILD is still limited

TRANSTHORACIC BIOPSY

• Lung biopsy remains the most definitive diagnostic

tool in interstitial lung disease Many of the classic

ILD disorders are still defined only by their histology

with alveolar wall thickening being the primary

marker Thoracoscopic techniques allow for minimallyinvasive sampling of lung tissue

MANAGEMENT OF ILD

• Management should be based on definitive diagnosis

• Treat underlying systemic disorders whenever possible

• Supportive care is of primary importance in the agement of ILD

man-1 Maintaining growth and nutrition is very importantand may require extra calories or tube feeding

2 Except with certain immunodeficiencies, all tine immunizations should be given, includinginfluenza vaccination Administration of antirespi-ratory syncytial virus (RSV) monoclonal antibod-ies should be considered, especially in youngchildren (<3 years old)

rou-3 Aggressively treat all infections

4 Environmental irritants or toxins should be avoided

• Medications used in treatment of interstitial lung ease

dis-1 Oxygen is recommended for chronic hypoxemia

2 Corticosteroids are still the mainstay for treatment

of interstitial lung disease They suppress overallinflammation Corticosteroids can be given in dif-ferent ways but most recommendations would sug-gest a trial of prednisone in the range of 1–2 mg/kg/day until patient improves or side effects occur.Other regimens include high-dose pulse steroids(10–30 mg/kg/day for 3 days given every 4 weeks)

3 Alternative but unproven therapy includes suppressive therapy with such agents as hydroxy-chloroquine, azathioprine, cyclophophamide, metho-trexate, cyclosporine, and intravenous immunoglo-bulin

immuno-• Lung transplantation is an option for end-stage ILD

PROGNOSIS FOR ILD

• Prognosis is variable depending on distinct etiology.Prognosis can range from full recovery to rapid pro-gression of disease with development of fibrosis, pul-monary hypertension, respiratory failure, and death.Overall mortality rate remains high at 16–20% (Fan andLangton, 1998)

B IBLIOGRAPHY

Fan LL, Langston C Interstitial lung disease In: Chernick V,

Boat T (eds.), Kendig’s Disorders of the Respiratory Tract of

Children Philadelphia, PA: W.B Saunders, 1998.

CHAPTER 161 • OTITIS MEDIA 527

Hillman BC Interstitial lung disease in children In: Hillman

BC (ed.), Pediatric Respiratory Disease: Diagnosis and

Treatment, 1st ed Philadelphia, PA: W.B Saunders, 1993,

pp 353–367.

Mark E Gerber

ACUTE OTITIS MEDIA

• Acute otitis media (AOM) is the second most common

infectious disease in children after viral upper

respira-tory infections

• Sixty-seven percent of children have one episode

prior to age 1 and 81% prior to age 3, most frequently

associated with viral upper respiratory infection

(URI)

• Risk factors for recurrent otitis media include the

fol-lowing:

1 Age (peak incidence is 6–13 months, with a second

peak at age 4–5 years)

2 Sex (slightly greater incidence in males)

3 Daycare attendance

4 Family history of otitis media

5 Formula feeding (and maybe pacifier/bottle use)

6 Cleft palate and other craniofacial abnormalities

7 Tobacco smoke exposure

DIAGNOSIS

• Antecedent or concurrent URI is usual Signs and

symptoms include irritability, decreased appetite,

diarrhea, fever, otalgia, pulling at ears, otorrhea,

hear-ing loss, and imbalance

• Physical examination shows tympanic membrane/

middle ear inflammation, characterized by erythema,

bulging, and loss of landmarks Pneumatic otoscopy

confirms middle ear fluid

THERAPY

• The most common bacteria are Streptococcus

pneu-moniae, Haemophilus influenzae, and Moraxella

catarrhalis In the first 2 weeks of life, group B

strep-tococcus, Staphylococcus aureus, Escherichia coli, and

Klebsiella pneumoniae are more common.

• Amoxicillin is the first line drug of choice Azithro-mycin,trimethoprim/sulfamethoxazole, or erythromycin/sul-fisoxazole are alternatives for penicillin allergic patients

• A 10-day course of treatment is recommended A 5–7day course may be adequate in children over 2 years

of age

• Patients under age 2 years should be rechecked in

2 weeks; 4 weeks may be appropriate for those over

treat-2 Second line antimicrobials that are appropriate

if there is improvement but the patient is stillsymptomatic include cefprozil, loracarbef, andazithromycin

3 Third line agents may be appropriate if there is dence of a more severe continued infection, withsymptoms such as fever, otalgia, and/or irritabilityafter 3 days of treatment These include amoxicillin-clavulanate, cefpodoxime, oral cefuroxime, or par-enteral ceftriaxone

evi-4 Relative and absolute indications for tesis and culture include acute otitis media in aseriously ill or toxic appearing child, an unsatis-factory response to empiric antibiotics, suppurativecomplications (facial nerve paralysis, mastoiditis,meningitis), and otitis media in a newborn orimmunologically deficient patient

tympanocen-5 Because of the risk of sensorineural hearing loss,audiometric testing is indicated when there is asuppurative complication of AOM

RECURRENT OTITIS MEDIA

• Otitis media that clears without residual MEEbetween infections but recurs within 6 weeks or less isdefined as recurrent acute otitis media

• Amoxicillin remains as the drug of choice with eachevent as long as it remains effective

• Prophylactic antibiotic therapy may be helpful if thereare more than four episodes in 12 months or threeepisodes in 6 months

1 Prophylaxis is indicated only when the intervalexamination shows no MEE

2 Gantricin and amoxicillin are the only drugsapproved for this indication, are only effective in20–30% of cases, and may increase antimicrobialresistance (amoxicillin > gantricin) Use for only

6 weeks at a time to minimize resistance

• Tympanostomy tubes are considered when there are

more than six episodes of AOM in 12 months or more

than four episodes in 6 months; however, many

chil-dren exceed this frequency without requiring

tympa-nostomy tube placement

OTITIS MEDIA WITH EFFUSION

• Otitis media with effusion is defined as asymptomatic

MEE with or without measurable hearing loss Fluid

may be serous or mucoid

• Thirty-three percent of effusions yield bacteria with

organisms similar to those seen in AOM

• Observation is appropriate if the patient is

asympto-matic Sixty-five percent resolve within 3 months

without therapy

• When present for more than 3 months, treatment with

tympanostomy tubes or antimicrobial therapy may be

indicated

1 Initial antimicrobial therapy is as recommended

for acute otitis media

2 Therapy can be repeated if the MEE is still present

4 weeks later

3 Antimicrobial prophylaxis is not indicated in the

treatment of otitis media with effusion due to

increased antimicrobial resistance without increased

rate of improvement

4 Tympanostomy tubes are indicated when there is

bilateral MEE >3 months, or unilateral MEE >6

months, especially if there is associated hearing loss

5 Adenoidectomy is effective in age 4–8 years when

undergoing a second set of tympanostomy tubes,

regardless of presence or absence of nasal

symp-toms Tonsillectomy has no effect on middle ear

disease

TONSILS AND ADENOIDS

• The tonsils and adenoids participate in regional

immunologic protection in the nasopharynx and

oropharynx, where they are part of the first line of

defense against inhaled or ingested antigens Chronic

inflammation results in reduction of effectiveness

against infection

RECURRENT INFECTION

• Recurrent infection is diagnosed when

adenotonsilli-tis occurs at a high frequency, defined as

1 Seven episodes/1 year

2 Five episodes/year for 2 years

3 Three episodes/year for 3 years

• The definition of “counting” episodes includes T

>38.5°C, cervical nodes >1cm, tonsillar exudate or (+)group A beta-hemolytic streptococcus (GABS) culture

• Adenotonsillectomy is indicated for recurrent sillitis Other factors that may be considered when decid-ing whether surgery should be performed include parentconcern with regard to the risk of rare GABS complica-tions or antibiotic resistance, parent/patient preferences,family tolerance of illness, patient tolerance of antimi-crobial therapy, and the patient’s surgical risk

adenoton-• Since the widespread availability and use of otics, the morbidity of tonsillitis has been dramaticallyreduced

antibi-UPPER AIRWAY OBSTRUCTION

• Upper airway obstruction secondary to adenotonsillarhypertrophy is the most common indication for ade-notonsillectomy

• Physical examination findings that suggest significantupper airway obstruction include adenoid faces andfailure to thrive

• Upper airway obstruction is often associated withsleep-disordered breathing Snoring alone is not a reli-able indicator of sleep-disordered breathing

1 Primary snoring (see Chapter 164) is estimated tooccur in up to 10% of the pediatric population

2 Nocturnal symptoms of sleep-disordered breathinginclude snoring with pauses/snorts/gasping, teethgrinding, restlessness, elevated respiratory effort(retractions) diaphoresis, periodic paradoxicalbreathing, frequent arousals, and secondary enuresis.Daytime symptoms include sleepiness/hyperactivity/impulsiveness, school problems/inattention, morn-ing headaches, nasal congestion, mouth breathing,and difficulty waking in the morning

• Upper airway obstruction syndromes with disordered breathing are characterized as high upperairway resistance syndrome (UARS) and obstructivesleep apnea syndrome (OSAS) These are discussed inChapter 164

sleep-• A clinical history that is suggestive of UARS (nighttimesymptoms of sleep-disordered breathing associated withdaytime symptoms related to sleep disruption) in apatient with adenotonsillar hypertrophy is an appro-priate indication for surgical intervention Pediatricpatients with either UARS or OSAS demonstrateimprovement in snoring, sleep fragmentation, day-time somnolence or hyperactivity, and other symp-toms related to sleep-disordered breathing followingadenotonsillectomy

CHAPTER 161 • OTITIS MEDIA 529

• Polysomnography (PSG) is indicated for patients who

are at high risk for general anesthesia and surgery

These include children with severe OSAS symptoms,

children <3 years old, and those with

cardiopul-monary disease, who are at increased risk of

postop-erative airway compromise

• Others that benefit from PSG include those patients

whose have small tonsils and adenoids or families that

need objective data to help their decision making

regarding therapy

• For patients who are not surgical candidates,

nonsur-gical treatment options such as continuous positive

airway pressure (CPAP) also reduce nighttime and

day-time symptoms PSG must be used to identify optimal

CPAP pressures

PREOPERATIVE EVALUATION

• Preoperative evaluation may vary depending on

sur-geon preference and hospital guidelines

1 Any patient with complex medical history should

undergo evaluation from an appropriate

preopera-tive evaluation by the specialist treating the

spe-cific problem

2 There remains controversy regarding the need for

routine preoperative laboratory studies, but due to

the lack of cost-effectiveness as well as inability to

predict which patient is at risk of postoperative

hemorrhage, it is not usually performed

3 A detailed bleeding questionnaire (Table 161-1) is

used to screen for possible bleeding disorder or the

need for coagulation studies Patients with positive

findings undergo screening coagulation studies (a

complete blood count, prothrombin time, partial

thromboplastin time, and platelet function analysis)

4 For African-American and other high-risk groups,

a sickle-cell screen should be considered if thepatient has not been previously tested

5 Laboratory evaluations specific to coexistent ical conditions may be necessary

med-SURGICAL TECHNIQUE

• Adenotonsillectomy is most commonly performedunder general anesthesia using a variety of surgicaltechniques Except for reported differences in operat-ing time and intraoperative bleeding, there are mini-mal differences with respect to postoperative bleedingrisk as well as outcome measures such as postopera-tive pain when a complete tonsillectomy is performed

• Benefits of adenotonsillectomy include reduction ofmouth breathing and improvement in behavioral prob-lems even when the upper airway obstruction is onlymild (without OSAS) preoperatively

• OSAS resolves after adenotonsillectomy in 90% ofcases Patients who do not demonstrate improvementtend to have smaller tonsils, narrower epipharyngealspace, and more poorly-developed maxillary andmandibular protrusion

• Adenotonsillectomy with or without additional surgeryoften improves OSAS in children with craniofacial

TABLE 161-1 Bleeding Questionnaire

Has your child ever had surgery, stitches for trauma, Yes No

or a broken bone?

If yes, was there more bleeding than expected during Yes No

or after?

Does your child bruise more easily than normal? Yes No

If a boy and circumcised, was bleeding more than expected Yes No

after the circumcision?

Was there bleeding when the umbilical cord came off? Yes No

Has your child had frequent nosebleeds? Yes No

Has your child bled more than normal after loss Yes No

of baby teeth?

Is your child taking aspirin or ibuprofen products? Yes No

If an older girl, is there a history of heavy menstrual periods? Yes No

Has your child ever needed a blood transfusion for prolonged Yes No

bleeding?

Do any blood relatives have an inherited bleeding problem Yes No

such as hemophilia, von Willebrand, or low platelets?

Has any blood relative been called a free bleeder? Yes No

anomalies and/or neuromuscular disorders These

patients are prone to increased postoperative airway

complications and prolonged hospitalization and

recovery postoperatively

Oren J Lakser

CLINICAL FEATURES

• Pneumonia is one of the most common serious

infec-tious causes of morbidity and mortality in children

around the world

• Diagnosis can be a challenge because of the diversity

in the clinical manifestations, which can vary

depending on the child’s age and the causative agent

• Classic symptoms include fever, tachypnea, and

cough On physical examination, children may

demon-strate tachypnea, diminished air entry, crackles and/or

wheezes, and in severe cases evidence of increased

work of breathing (retractions, accessory muscle use,

or nasal flaring) Hypoxemia may be present, but is

often a late sign Absence of tachypnea is a strong

indi-cation that the child does not have pneumonia.

• These symptoms may frequently be preceded by

minor upper respiratory infection symptomatology

including low-grade fever and rhinorrhea

LABORATORY INVESTIGATIONS

• The variability in the clinical manifestations of

pneu-monia makes history and physical examination less

conclusive at arriving at a definitive diagnosis

Laboratory tests have a minimal role in patients with

uncomplicated community-acquired pneumonia, but

can aid in patient management particularly in

ill-appearing patients

• Leucocytosis (WBC >15,000–20,000/mm3) in

associ-ation with fever higher than 39°C often suggests a

bacterial etiology Blood cultures are positive in less

than 3% of pediatric outpatients with pneumonia, but

may be informative in patients with severe cases of

pneumonia and for infants under 3 months of age

Cultures and serologic testing for Mycoplasma

pneu-moniae or Chlamydia pneupneu-moniae are not

recom-mended as routine studies Similarly, viral cultures

and antigen detection, or cold agglutinins should only

be obtained when they will alter management sions Gram stain and culture on respiratory secretions(sputum, bronchoalveolar lavage, or pleural fluid) can

deci-be helpful, but are often difficult to obtain An quate sputum culture should have <10 squamousepithelial cells and >25,000 white blood cells per lowpower field

ade-• Chest radiography can be helpful in confirming the ence and location of a pneumonia; however, a normalchest x-ray does not rule out pneumonia as many patientswith evolving pneumonia can have normal chest x-rays.Chest x-rays can occasionally differentiate between bac-terial and viral pneumonias Bacterial pneumonias oftenpresent with lobar consolidation, whereas viral pneumo-nias are characterized by interstitial, peribronchial, orbilateral bronchoalveolar infiltrates

pres-MANAGEMENT

• Indications for hospitalization include significantincrease in work of breathing or toxic appearance,oxygen requirement (saturation <92%), infants <2months of age, presence of moderate-to-large pleuraleffusions, or underlying chronic disease such as cysticfibrosis or sickle cell disease

• Inpatient antibiotic choice is guided by the patient’sage Neonates 0–30 days should receive ampicillinand gentamicin unless another specific cause is iden-tified Children between 1 month and 5 years shouldreceive a third generation cephalosporin, such as cefo-

taxin If Chlamydia trachomotis or Bordetella

pertus-sis are suspected, a macrolide antibiotic should be

initiated Hospitalized children over 5 years of ageshould be started on a third generation cephalosporinAND a macrolide antibiotic Duration of therapydepends on the patient’s response but in general is10–14 days for infants up to 3 months of age and 7–10days for children older than 3 months

• Outpatient antibiotic choice is determined by the pected etiologic agent and the patient’s age (seeFig 162-1) In children 60 days to 5 years of age whoare suspected of having a bacterial infection high-doseamoxicillin (80–90 mg/kg/day) or amoxicillin/clavu-lanate should be initiated In some children, an initialparenteral dose of ceftriaxone may be considered ifthere is concern about the child tolerating the initialdoses of the oral medication (e.g., vomiting) In chil-dren over 5 years of age a macrolide antibiotic should

sus-be initiated and some clinicians will include a sus-lactam agent as well If the causative agent is pre-sumed to be viral (respiratory syncytial virus,influenza, or parainfluenza virus), the most common

beta-CHAPTER 162 • PNEUMONIA 531

cause of pneumonia in children over 2 months of age,

antibiotics are not warranted and the child should be

managed symptomatically

• Parapneumonic effusions should be suspected when

dullness to percussion, decreased fremitus, and egophany

are present on physical examination or the patient fails

to improve or relapses after initial improvement

Upright and/or lateral decubitus chest x-rays should be

done Occasionally a chest commuted tomography scan

or magnetic resonance imaging may be helpful A

diag-nostic/therapeutic thoracentesis should be performed in

any ill-appearing patient, preferably prior to initiation of

antibiotics Children with parapneumonic effusions

should receive a minimum of 10 days of parenteral

antibiotics to cover the discovered or suspected etiologicorganism Occasionally, surgical intervention (chesttube or decortication) may be warranted

B IBLIOGRAPHY

Mahabee-Gittens EM Pediatric pneumonia Clin Pediatr Emerg

Med 2002;3:200–214.

McCracken GH Diagnosis and management of pneumonia in

children Pediatr Infect Dis J 2000;19:924–928.

McIntosh K Current concepts: Community-acquired pneumonia

in children N Engl J Med 2002;346:429–437.

Patient appears toxic, hypoxemic, increased work of breathing

Confident bacterial pneumonia

No antibiotics Obtain a chest radiograph

Still suspect bacterial?

Lobar consolidation

Patient demonstrates focal crackles or diminished air entry

Viral pneumonia more likely

Consider appropriate inpatient management with parenteral antibiotics

Interstitial or peribronchiolar pattern

Treat according to age

No antibiotics

Viral pneumonia more likely

>5 years

60 days to 5 years

Macrolide +/ − beta lactam

High dose amoxicillin (80–90 mg/kg/day) or amoxicillin/clavulanate

Fever, tachypnea, and cough

FIG 162-1 Algorithm for the

manage-ment of outpatient community-acquired

pneumonia.

163 CYSTIC FIBROSIS

Susanna A McColley

DEFINITION

• Cystic fibrosis (CF) is an autosomal recessive

multisys-tem disorder caused by mutations in the cystic fibrosis

transmembrane regulator CFTR gene CFTR codes for

an epithelial cell membrane-bound protein that conducts

chloride through the apical cell membrane and serves as

a regulator of other membrane ion channels Absent or

dysfunctional CFTR causes abnormal ion transport onto

epithelial surfaces, resulting in dehydrated surface fluid

The major clinical manifestations are sinopulmonary

disease, digestive tract abnormalities, male infertility,

and excessive salt loss through the sweat glands Cystic

fibrosis occurs in 1:3300 live births in Caucasians in the

United States It is less frequent in other populations

CLINICAL PRESENTATION

• Prenatal diagnosis is increasingly made by genetic

testing via amniocentesis or chorionic villus sampling

Echogenic bowel may be seen on prenatal ultrasound

• Neonatal screening is currently performed in some

geographic areas In the United States this test usually

combines an assay for immunoreactive trypsinogen

(IRT) and analysis for one or more common cystic

fibrosis gene mutation

• Meconium ileus is a neonatal bowel obstruction that

occurs in 15–20% of affected infants Meconium plug

syndrome is a milder variant of this disorder

• Prolonged cholestatic jaundice is seen in a small

number of neonates with CF

• Lower respiratory tract symptoms leading to

diagno-sis include chronic or recurrent cough, pneumonia, or

bronchitis, recurrent or persistent wheezing, and

“bronchiolitis syndrome” in infants

• Upper airway findings include severe or persistent

paranasal sinusitis and nasal polyposis

• Pancreatic insufficiency is present in approximately

85% of patients and results in growth failure,

diges-tive symptoms, or both

1 Growth failure may be present, especially after

6 months of age Appetite is variably poor, average,

or voracious

2 Digestive symptoms include steatorrhea,

charac-terized by large, bulky stools which may be very

malodorous and/or frankly oily

3 Frequent or large bowel movements may be

reported Rectal prolapse may occur, especially in

children who are toilet learning

• Chronic metabolic alkalosis or acute hypochloremic,hyponatremic dehydration are common presentations

in warm climates and during summer months

• Symptoms of fat-soluble vitamin deficiency may beseen, such as night blindness or bleeding diathesis

DIAGNOSIS

• Quantitative pilocarpine iontopheresis sweat chloridetesting is the initial study of choice for infants orchildren with characteristic symptoms, a positive new-born screening test, or a history of an affected sibling.Sweat chlorides >60 meq/L are diagnostic of CF inthese settings Borderline sweat chlorides, 40–60meq/L, are seen in some patients, especially thosewith mild or atypical phenotypes Normal sweat chlo-rides (<40 meq/L) have been seen in patients withgenetically confirmed cystic fibrosis and may be seen

in some infants with CF on initial testing

• Confirmation of a CF diagnosis requires a secondsweat test or genotyping which reveals two CF-causing gene mutations

• Nasal potential difference (NPD) measurement may

be needed for diagnosis in symptomatic individualswith normal or borderline sweat tests and nondiag-nostic CF genotype NPD is available through someCystic Fibrosis Research Centers

COMPLICATIONS

• Progressive pulmonary disease, characterized by chronicairway infection, inflammation, and obstruction, is themajor cause of morbidity and mortality in cystic fibrosis

• Pulmonary exacerbation of cystic fibrosis is characterized

by increased cough and increased sputum production;hemoptysis may be seen Weight loss and decreased pul-monary function are frequently present Fever is unusual

• Predominant cystic fibrosis pathogens are Pseudomonas

aeruginosa and Staphylococcus aureus Hemophilus influenzae, Stenotrophomonas maltophilia, Achromo- bacter xylosoxidans, and Burkholderia cepacia are also

frequently seen, as are Aspergillus fumigatus and

nontu-berculous mycobacteria

• Allergic bronchopulmonary aspergillosis occurs in4–15% of patients Acute or subacute clinical deteriora-tion, markedly elevated serum IgE level (>1000 IU/mL),

immediate cutaneous reactivity to Aspergillus

fumiga-tus, precipitating antibodies to A fumigafumiga-tus, and new

or recent abnormalities on chest imaging are teristic of this complication

charac-• Nasal polyposis and symptomatic sinusitis arecommon complications

• Poor growth and nutrition may be seen and are ated with worse intermediate and long-term outcomes

associ-CHAPTER 163 • CYSTIC FIBROSIS 533

• Gastroesophageal reflux and gastritis and/or

duodeni-tis may occur

• Individuals with pancreatic insufficiency are at risk of

fat-soluble vitamin deficiency (A, D, E, and K)

• Distal intestinal obstruction syndrome is caused by

dehydrated, bulky feces and is characterized by

con-stipation or obcon-stipation, abdominal pain, and,

charac-teristically, a right lower quadrant mass

• Elevated liver function tests, cirrhosis, and gallstones

may occur

• Pancreatitis occurs primarily in patients with residual

pancreatic function

• Most affected men are infertile due to absence of the

vas deferens; women may have reduced fertility, but

recent data suggest that this reduction is only slight if

it is present at all

• Arthropathy occurs primarily in patients with

signifi-cant pulmonary disease

• Glucose intolerance increases with age and affects up

to 75% of adolescents Diabetes mellitus mostly

occurs in patients over 12 years of age; by adulthood,

at least 25% of patients require therapy for diabetes

TREATMENT

• Patients have improved outcomes when cared for in

specialty centers with multidisciplinary care teams

The Cystic Fibrosis Foundation Clinical Practice

Guidelines recommend center visits on a quarterly

basis for stable patients >6 years of age; younger

patients or those with more health problems may

ben-efit from more frequent visits

• Nutritional therapy includes a high-calorie diet with

unrestricted fat, supplementation of fat-soluble

vita-mins, preferably in water-soluble forms, and pancreatic

enzymes for pancreatic insufficient patients Close

mon-itoring of nutritional status by a dietician is essential

1 Supplemental feedings by nasogastric or

gastros-tomy tube may be necessary to achieve adequate

growth and nutrition

2 Use of H2 blockers or proton pump inhibitors

improves enzyme effectiveness and is effective in

reducing symptoms of gastroesophageal reflux

dis-ease (GERD) and gastritis

• Most experts recommend institution of airway

clear-ance techniques at the time of diagnosis Technique is

chosen based on the patient age, condition, and

patient and family preferences Manual chest

percus-sion with postural drainage, high-frequency chest wall

oscillation, positive expiratory pressure devices, and

autogenic drainage are all useful in enhancing

mucociliary clearance and clearing viscid secretions

from the airways Patients who are asymptomatic or

who have mild pulmonary disease generally receive

one to two sessions per day; more severely affectedindividuals may need more frequent therapy

• Recombinant human DNase reduces sputum viscosity,improves pulmonary function modestly, and decreasesthe frequency of pulmonary exacerbation The usualdose is 2.5 mg inhaled via nebulizer once daily

• Most patients are administered short- or long-actingbeta-agonists as an adjunct to airway clearance; retro-spective studies suggest a benefit of these agents, but

no well-controlled clinical trials exist Inhaled costeroids are also frequently administered

corti-• High-dose ibuprofen may reduce pulmonary functiondecline and improve nutrition Pharmacokinetic stud-ies must be used to ascertain the optimal dose

• Frequent monitoring of respiratory tract microbiology isrecommended Pharyngeal swabs or nasopharyngealsuction specimens are obtained on nonexpectoratingpatients, and sputum specimens on expectorating patients.Special culture techniques should be used to identify

Burkholderia cepacia and to test for Staphylo-coccus aureus when Pseudomonas aeruginosa is present.

• Patients with Pseudomonas aeruginosa and

mild-to-moderate lung disease benefit from chronic intermittenttherapy with inhaled high-dose tobramycin A dose of

300 mg twice daily of a preservative-free preparation isinhaled for 28 days followed by 28 days off

• Patients with Pseudomonas aeruginosa also benefit

from azithromycin given at a dose of 250 mg 3 daysweekly for patients <40 kg and 500 mg 3 days weeklyfor patients ≥40 kg

• Chronic use of antistaphylococcal antibiotics in youngchildren remains controversial One study of cephalexinshowed no pulmonary function benefit and an increase in

Pseudomonas aeruginosa infection among patients

treated with long-term cephalexin vs placebo Pulmonaryexacerbation is treated with antibiotics These may begiven orally or intravenously depending on the patient’sfindings and culture results Patients with significantweight loss and/or decreases in pulmonary functionshould be treated with intravenous antibiotics; duration oftherapy is at least 14 days Chest physiotherapy should beincreased during pulmonary exacerbation to three to foursessions daily Evidence from epidemiologic and retro-spective studies suggests that in-hospital care and longerintravenous antibiotic duration are associated withimproved patient outcomes

• Diabetes should be managed aggressively for goodglycemic control

• Abnormal liver function tests often improve withadministration of ursodeoxycholic acid Liver trans-plantation is very successful in patients with cirrhosis,provided pulmonary disease is stable

• Distal intestinal obstruction syndrome is treated with

a balanced intestinal lavage solution, given by mouth

or via nasogastric tube Milder episodes of constipation

may be treated with stool softeners Adjustment of

enzyme dose is helpful in preventing recurrence

• Intracytoplasmic sperm injection allows men with

CF to father children in vitro Carrier testing for the

partner and genetic counseling are essential for

cou-ples considering this treatment for infertility

• Lung transplantation is an option for some patients

with end-stage lung disease

PROGNOSIS

• More than 90% of deaths are secondary to respiratory

failure Progression of disease is variable

• Median life expectancy continues to increase and is

currently between 30 and 35 years, with many affected

individuals living into their 40s, 50s, and beyond

B IBLIOGRAPHY

Boat TF Cystic fibrosis In: Behrman, Kleigman, Jenson (eds.),

Nelson Textbook of Pediatrics, 17th ed Philadelphia, PA: W.B.

Saunders, 2003, pp 1437–1450.

Clinical Practice Guidelines for Cystic Fibrosis Bethesda MD:

Cystic Fibrosis Foundation.

McColley SA Cystic fibrosis In: Rakel, Bope (eds.), Conn’s

Current Therapy 2002 Philadelphia, PA: W.B Saunders,

2002, pp 179–184.

BREATHING

Stephen H Sheldon

NORMAL AND ABNORMAL

RESPIRATORY EVENTS DURING SLEEP

• Pauses in breathing are normal during sleep in infants,

children, and adolescents Clinical significance of

res-piratory pauses varies according to the child’s

post-conceptional age, developmental status, and comorbid

medical and anatomical conditions Types of

respira-tory pauses during sleep include obstructive apnea,

central apnea, periodic breathing (PB), mixed apnea,

postsigh central apnea, expiratory apnea, central

hypoventilation, and obstructive hypoventilation

OBSTRUCTIVE APNEA SYNDROME (OSAS)

CLINICAL FEATURES

• During an obstructive apnea, there is complete cessation

of airflow through the nose and mouth despite continuedinspiratory and expiratory respiratory efforts (see Fig.164-1) Absence of airflow may be brief, lasting

6 seconds or less Two obstructed respiratory effortsmay be clinically significant, especially when theobstruction is periodic and frequent Occasionally, theobstructive apnea can be prolonged and associatedwith oxygen desaturation, cardiac deceleration, car-diac arrhythmia, and carbon dioxide retention

• Snoring is a characteristic feature of OSAS Nonetheless,some children with significant OSAS have minimal snor-ing Snoring is often associated with pauses and snorts.Difficulty breathing during sleep, restless sleep, diaphore-sis, morning headaches, excessive thirst on waking,nightmares, sleep terrors, frequent nocturnal waking,and sleep-related enuresis (especially secondary enure-sis) are common associated symptoms

• Daytime symptoms include, but are not limited toexcessive sleepiness, hyperactivity, attention spanproblems, poor school performance, behavioral abnor-malities, unusual aggressiveness, moodiness, andexcessive shyness Difficulty learning in school, fre-quent upper airway infections, sinusitis, frequent otitismedia, failure-to-thrive, and obesity may also be pres-ent In severe cases, pulmonary hypertension and corpulmonale can develop

• In the otherwise normal child, the most common lying etiology is hypertrophy of the tonsils and adenoids

under-• Children with craniofacial malformations of the dible (e.g., micrognathia as in Pierre-Robin Sequence),maxillae (e.g., maxillary hypoplasia as in Apert syn-drome), or any other defect of the midface are at par-ticular risk Children with high-arched palate are also

man-at risk for OSAS

• Children with central or peripheral neurologic malities that result in decreased or increased muscletone may exhibit OSAS due to dysfunction of pharyn-geal musculature and/or uncoordinated pharyngealmuscle activity

abnor-• Patients with Down syndrome, achondroplasia, andPrader-Willi exhibit both anatomical and neurologicabnormalities that place them at high risk for OSAS

TREATMENT OPTIONS

• Since the most common cause of OSAS in otherwisenormal children is hypertrophy of tonsils and adenoids,tonsillectomy and adenoidectomy is the mostcommon therapeutic intervention in children

CHAPTER 164 • SLEEP DISORDERS AND BREATHING 535

• Identifiable causes of upper airway obstruction should

be identified and appropriately managed

• Nasal continuous positive airway pressure (CPAP)

and bilevel positive airway pressure (biPAP) can also

be used in treatment of children with OSAS

• Tracheostomy bypasses upper airway obstruction and

results in cure of OSAS Nonetheless, it is typically

reserved for those severe patients who are at high risk

of severe sequelae and OSAS cannot be treated using

other less invasive techniques

SEQUELAE OF OSAS

• Cor pulmonale and mortality secondary to OSAS

during sleep in children with hypertrophied tonsils and

adenoids is unusual Cardiac arrhythmias may occur

and may be associated with occlusive respiratory

events

• Excessive daytime sleepiness, hyperactivity, attention

span problems, learning difficulties, and behavioral

abnormalities contribute to significant morbidity fromundiagnosed and untreated OSAS

• Functional neurocognitive sequelae of OSAS havebeen well documented in adults and children withsignificant effects including but not limited to deficits

of attention, concentration, psychomotor skills,memory, and high cognitive or executive functions.Neuropsychologic deficits seem to vary with severity

of hypoxemia and excessive daytime somnolence

CENTRAL SLEEP APNEA (CSA) AND PERIODIC BREATHING

CLINICAL FEATURES

• The definition of “central apnea” differs depending

on the patient’s postconceptional age In theneonate, a central apnea is defined as abnormalwhen there is absence of airflow through the noseand mouth associated with absence of chest and

FIG 164-1 Obstructive apnea 60-second epoch.

abdominal respiratory effort that last 20 seconds or

longer Shorter apneas may be significant if

associ-ated with oxygen desaturation or heart rate changes

(see Fig 164-2)

• Prolonged central apneas related to the absence of

both inspiratory and expiratory neuronal activity

appear to be quite rare in otherwise normal infants

and children during Quiet/NREM sleep Brief central

apneas are normal during Active/REM sleep.

• PB is a pattern of respiration characterized by three or

more central pauses lasting 3 seconds or longer, and

separated by less than 20 seconds of normal

breath-ing PB occurs normally in premature infants,

espe-cially during Active/REM sleep (see Fig 164-3) In

the very premature infant, PB may also occur during

Quiet/NREM sleep This pattern of breathing

repre-sents immaturity of central control of breathing and

typically resolves as conceptional term is reached In

the term infant, PB occurs almost exclusively during

Active/REM sleep Persistence of PB during long

portions of sleep or during Quiet sleep may be

abnormal and reflect immaturity and/or abnormality

of central control of breathing

THERAPEUTIC CONSIDERATIONS

• Methylxantines are typically effective in treatment ofapnea of prematurity Caffeine citrate is commonlyused For apnea of prematurity a loading dose of10–20 mg/kg as caffeine citrate (5–10 mg of caffeinebase) may be given orally or intravenously A mainte-nance dose of 5–10 mg/kg/day (2.5–5.0 mg/kg/day ofcaffeine base) once daily starting 24 hours after theloading dose is then begun

• Caffeine has advantages over other methylxantines(e.g., theophylline) in the wider therapeutic windowand the need for only a single daily dose

• Apnea of prematurity resolves between 40 and 44weeks postconception Caffeine can typically be dis-continued after this time

FIG 164-2 Central apnea 30-second epoch.

CHAPTER 164 • SLEEP DISORDERS AND BREATHING 537

SLEEP-RELATED HYPOVENTILATION

CLINICAL FEATURES

• Hypoventilation is defined as ineffective ability of the

respiratory system to exhale carbon dioxide It is often

associated with inadequate oxygenation, but

hypox-emia is not always present

• Central hypoventilation occurs when there is

inade-quate ventilation due to inadeinade-quate output from

brain-stem respiratory centers Dysfunction may be

congenital (congenital central hypoventilation

syn-drome [CCHS]) or may be acquired abnormalities of

the brain stem Most children with CCHS have normal

respiratory rates, but breathe very shallowly during

sleep Other children with central hypoventilation

may have normal or increased tidal volume, but

sig-nificantly reduced respiratory rate

• Obstructive hypoventilation occurs when there is

chronic upper airway obstruction associated with

high upper airway resistance Overt apnea may or

may not be present Respiratory rate during sleepmight be increased, and oxygen saturation is oftenwithin normal range EtCO2remains greater than 50mmHg for a significant portion of the total sleeptime and the maximum EtCO2 is often greater than

55 mmHg

DIAGNOSTIC METHODS

• Accurate diagnosis of respiratory pauses during sleep

in children is based on comprehensive attended tinuous monitoring of respiratory, cardiovascular, and

con-electroencephalographic parameters across the child’s

habitual sleep time This is termed nocturnal

polysomnography Since severity of breathing ders during sleep often varies across the 24-hour con-tinuum, with the highest incidence of pathologicapnea occurring during the early morning hours,monitoring of sleep is most reliable when performed

disor-at night, during the child’s major sleep period

FIG 164-3 Periodic breathing 60-second epoch.

• In addition to recording and analyzing sleep state and

architecture, nasal and oral airflow may be measured

using different methodology Most reliable involves

recording airflow by pressure transduction at the nose

and mouth Capnography provides an assessment of

airflow by continuous measurement of exhaled carbon

dioxide (and provides an assessment of EtCO2)

Thermistry (using either thermistor or thermocouple

placed in the air stream) provides a qualitative

mea-surement of airflow and is considered less reliable

than nasal pressure and EtCO2

• Respiratory effort is monitored either by piezo crystalstrain gauges that continuously monitor changes incircumference of the chest and abdomen or by induc-tive plethysmography measuring changes in volumes

of the chest and abdomen

• Continuous monitoring of SaO2, electrocardiogram(ECG), and intermittent monitoring of TcPCO2 arealso recorded

• The overall prevalence of psychiatric disorder among

children and adolescents approaches 20%, with 11%

classified as severe and 5% extremely severe The vast

majority of children with a diagnosis, however,

receive no treatment, with 50–80% having mental

health needs that aren’t being met If all children with

psychiatric disorders (those warranting a psychiatric

diagnosis) were identified and referred for treatment,

however, the secondary (Community Mental Health

Centers) and tertiary care facilities could not manage

the patient load As a public health issue, greater

recognition is important, but better venues for

provid-ing treatment must be developed

• With most children receiving periodic pediatric care,

and many receiving very regular care, it is not

sur-prising that estimates of psychopathology among

chil-dren in pediatric practices are high For both

school-age and preschool-age children, the prevalence

of psychiatric problems is in the midteens, but a large

percentage (about half) go unrecognized Given the

time demands on pediatricians to attend to a variety of

health, nutrition, and developmental factors during

10–15-minute outpatient visits, this should not be too

surprising Improved recognition is important from a

public health perspective, but practical

implementa-tion of improved screening may require

improve-ments in treatment delivery to be meaningful

• Pediatricians working with a child who appears to beexperiencing mental health difficulties must makedecisions about who should be evaluated and treated.Essentially, there are two models the pediatric prac-tice can implement The first is an office model inwhich the pediatrician either provides treatmentdirectly (advice giving, counseling, pharmacother-apy), or refers to a mental health specialist working inthe practice setting The second is a referral model, inwhich the physician refers to mental health specialistsoutside the practice and provides little in-office care

• In this chapter, information is presented about anarray of behavioral and emotional problems that maypresent in a primary care setting Some, like attentiondeficit hyperactivity disorder (ADHD), are relativelycommon; others, less so Whether the pediatrician isproviding treatment through his/her practice, or hasmade a referral for treatment but is playing a role incoordination of care, an understanding of the basicconditions and the available evidence for treatment isimportant Each section refers to clinical aspects ofthe disorder, diagnostic issues, and treatment options.Pediatricians may not be familiar with the basic types

of treatment that a mental health professional mightprovide The next section provides an overview ofpsychologic treatments, while the subsequent sectiondiscusses some of the more common medicationsused in the treatment of psychologic problems of chil-dren and adolescents

PRINCIPLES UNDERLYING THE DEVELOPMENT OF PSYCHOPATHOLOGY

• Approaches to child treatment should be ized within a biopsychosocial framework, one thatrecognizes the role of biologic, psychologic, and

conceptual-Section 20

BEHAVIORAL AND PSYCHIATRIC

DISORDERS

539

John V Lavigne and D Richard Martini, Section Editors

Copyright © 2005 by The McGraw-Hill Companies, Inc Click here for terms of use.

social factors on development in general, and the

development of problematic behaviors and emotional

responses more specifically Biologic factors certainly

include genetic predispositions to behavior, along with

prenatal and perinatal contributions to development

Temperamental characteristics—those personality

traits that have a strong biologic basis—are usually

rec-ognizable in infancy and preschool years, and have

important influences on the individual’s style of

behav-ing There are theoretical differences in how these

temperamental characteristics are conceptualized, but

the characteristics generally recognized include

indi-vidual differences in activity level, mood, intensity of

response, approach vs avoidance of novel situations,

persistence, and sociability (e.g., introversion/

extraversion) Clusters of temperamental traits (e.g., a

cluster of traits contributing to a child’s tendency to be

slow to warm up to new social situations, or to be

dif-ficult to manage because of the child’s intensity in

expressing affect, persistence, and negative mood) can

all contribute directly to the child’s behavior, have an

influence on parent-child interaction patterns, and

have far-reaching implications for the child’s behavior

• Children are raised in a social context The community

shapes the child’s exposure to models of behavior in a

multitude of ways, not the least of which include

expo-sure to violence, and to positive influences that

con-tribute to the individual’s achievement orientation The

school context and the child’s exposure to educational

opportunities flow through the community, as do

opportunities for, and access to, quality health care Of

paramount importance as a social influence is the

child’s family context Families exist, in large part, to

nurture and socialize children Children are adaptable

and there is a great deal of plasticity in the child

social-ization process, such that many different approaches to

child rearing can produce a “just fine” adult

(recogniz-ing the wide variety of outcomes that can be just fine).

Still a variety of family and community conditions can

place a child at risk for a less than optimal outcome

and contribute to problematic behaviors and emotional

responses Poverty, parental psychopathology, family

conflict, and differences in child-rearing practices can

shape the individual child and influence their behavior

• The child’s cognitive and language development

inter-acts with the biologic factors and social context noted

above to influence the child’s behavior Children are

not passive recipients of the social influences

surround-ing them They act on their environments constantly in

a reciprocal influence process They act, observe the

consequences of their actions, and alter their behaviors

accordingly They assimilate what they see and hear

into the internal, cognitive frameworks they have for

processing information, and these cognitive

frame-works evolve as a function of maturation and theirsocial experiences Society, and especially their family,influences them, and they in turn have an impact ontheir families and (collectively) on the broader society

• Treatments for child behavior and emotional lems take place with a recognition of the broad set offactors that influence the child In a sense, because ofthe powerful influences that families have, all inter-ventions with children are family interventionsbecause they recognize the role that families have onthe child’s behavior

prob-• Interventions vary in their complexity, but even the atively simple process of informing a family abouthow to administer a prescribed medication to a child ofthe family context and the parent’s ability to followthrough Primary care pediatrics requires that the pedi-atrician provide advice on health, feeding and nutri-tion, toilet training, child safety, and so on, and thebroader the awareness of the family’s capacity tofollow through on instructions, and the more adaptablethe physician can be in the advice that is given, themore likely it will be that an intervention is successful

rel-• At times, pediatricians will be confronted with tions about a child’s behavior problem that requirereferral for consultation with a mental health special-ist Throughout this chapter, reference in made toavailable psychotherapy and psychopharmacologicoptions for treatment, and a brief discussion of differ-ent approaches seems to be in order

ques-EVALUATIONS OF CHILDREN AND ADOLESCENTS

• Critical to most evaluations of children’s behaviorproblems are interviews with parents and the child.Parent interviews are essential for obtaining an ade-quate description of the presenting problems and theironset, and establishing the presence of other psychi-atric symptoms Parent interviews are also critical forobtaining information about prior psychologic treat-ment, family problems, stressors, the child’s peer rela-tionships, and academic performance as well asrelevant medical history Child interviews play animportant role in understanding emotional symptomsthe child is experiencing (e.g., anxiety and depres-sion), their view about other problem behaviors andabout their school and family life Interviews with thechild are often less productive with younger children,and observations of their behavior may supplement orreplace any interview Obtaining information fromother observers, particularly teachers, is very helpful.This can be done by telephone interviews or withquestionnaires, a particularly important source of