Asthma

A 5-year-old boy was brought for evaluation of ongoing thrombocytopenia before undergoing adenotonsillectomy for obstructive sleep apnea. The child had been given a diagnosis of "growing pains" after frequent evaluation for leg pain over the past 2 years.

A 16-year-old boy with Down syndrome was referred for evaluation of nonspecific symptoms, including difficulty in breathing on standing up from a sitting position, dizziness, frequent abdominal pain, and diarrhea after ingesting fatty foods and milk. He had intermittent asthma exacerbations for which he occasionally used a β-agonist. He had no history of trauma, surgery, or allergies.

“My 8–year–old son has always had trouble falling asleep. He never falls asleep before 11 PM, even on school nights. Is there anything you can prescribe so he can get to sleep earlier?”

Researchers at the University of California, San Francisco, Institute for Health Policy Studies found that school-based asthma education does improve self-management behaviors; however, it has less consistent effects on health outcomes.

Episodic right-sided facial flushing was noted in a 2-month-old girl born at full term via forceps-assisted vaginal delivery. The erythema appeared within minutes of latching onto her mother’s breast and resolved within 5 to 10 minutes after breastfeeding. The episodes of flushing had begun a week before the clinic visit; there were no collateral symptoms of anaphylaxis. Because food allergy was suspected, the mother had eliminated all dairy products from her diet.

A 5-month-old Asian boy was brought for evaluation of hair loss and a red, scaly rash on the scalp and body. The rash had not responded to hydrocortisone 2.5% ointment. There was a family history of asthma, food allergies, and allergic rhinitis. His mother had Hashimoto thyroiditis.

Asthma exacerbations continue to cause a significant number of emergency care visits and hospitalizations among children.1 In “Managing Asthma in Children, Part 1” (CONSULTANT FOR PEDIATRICIANS, May 2009, page 168), we reviewed the epidemiology, risk factors, and diagnosis of asthma in children. We also discussed how to make an initial assessment of asthma severity. In Part 2, we review the key components of treatment.

Asthma is one of the most prevalent chronic diseases in the United States, and most medical practitioners encounter patients with asthma on a daily basis. The goal of this 2-part article is to discuss the diagnosis and management of asthma in children younger than 12 years. In part 1, we will briefly outline the epidemiology, pathophysiology, and risk factors; then we will review, in more detail, the diagnosis of asthma and the initial evaluation of asthma severity.

The most common chronic medical problem that we pediatricians treat is asthma. We do our best to manage our patients’ asthma by prescribing controller medications, providing asthma action plans, and guiding families through acute exacerbations. We often ask about possible environmental triggers, such as tobacco smoke and cockroaches, and we advise patients to reduce their exposure to those triggers.

An African American baby girl was noted to have noisy breathing at birth. The infant had inspiratory stridor while awake and no audible stridor while asleep. Birth weight was 3.20 kg (7.11 lb). She had been formula fed for the first 2 weeks of life and had intermittently vomited after feedings.

The most common chronic medical problem that we pediatricians treat is asthma. We do our best to manage our patients' asthma by prescribing controller medications, providing asthma action plans, and guiding families through acute exacerbations. We often ask about possible environmental triggers, such as tobacco smoke and cockroaches, and we advise patients to reduce their exposure to those triggers.

For the past few weeks, a 10-year-old boy had a pruritic abdominal rash that had not responded to over-the-counter topical medications. The rash had appeared around the time he started wearing a new belt (shown). The child was otherwise healthy. There was a family history of asthma.

I read with keen interest Dr Jack Gladstein's article, "Pediatric Migraine: Strategies for Maintaining Control," in the August issue of CONSULTANT FOR PEDIATRICIANS (page 316). It prompted several follow-up questions, which I hope the author can respond to.

A 16-year-old boy presented for evaluation of asthma and exercise-induced bronchospasm. His parents recalled an episode 2 months earlier in which the patient, while jumping on a trampoline and wrestling with his brother, felt like he could not catch his breath. He took a puff of his rescue inhaler, and soon after, passed out. He remained unresponsive for 2 hours.

For 3 days, a 6-year-old boy had nonpruritic, painful lesions on the soles of both feet. His mother reported that he had difficulty in sleeping and walking but had no fever or other systemic symptoms.

You sign his required college forms and give him his meningitis vaccine. As you prepare to say "good luck," you wonder what counsel you can offer to help him become a healthy and educated medical consumer and patient.

In children, most causes ofitching are the result of skin disease,not underlying systemic illness. The mostcommon dermatological causes of pruritusare atopic and contact dermatitis,urticaria, miliaria rubra, infections, insectbites or infestations, xerosis, and aquagenicpruritus. A careful history andphysical examination usually reveal thediagnosis. The location, chronicity, timeof occurrence, and nature of the itchingoffer important diagnostic clues, as doprecipitating factors, associated symptoms,drug use, exposure to infectious diseasesor pets, psychosocial history, past health,and family history. Treatment of the underlyingcause of itching should beaddressed whenever possible. Symptomatictreatment is essential to breakthe itch-scratch cycle.

A 2-year-old previously healthy girl was brought to her pediatrician with the chief complaint of persistent noisy breathing. Two months earlier, the child had an upper respiratory tract infection (URI) with rhinorrhea, cough, noisy breathing, and wheezing. All symptoms had resolved except the abnormal breathing. Physical examination findings were unremarkable. A lateral neck x-ray film demonstrated subglottic narrowing, thought to be consistent with croup. Laryngoscopic examination by an otolaryngologist did not reveal any pathology.

Despite the plethora ofover-the-counter cough and cold medicationsdesigned to relieve a variety ofsymptoms of the common cold-primarilynasal congestion, rhinorrhea, and cough-no treatment has been shown to have anybeneficial effect in children, and some maycarry a substantial risk of adverse effects.Even routine symptomatic therapies suchas antipyretics and humidified air maybe counterproductive. Parental educationis the best medicine. Parents need tounderstand the duration and expectedsymptoms of the common cold. Advisethem about specific changes in symptoms(eg, rapid or labored breathing) or duration(eg, a cold lasting 10 days or morewithout improvement) that would warranta re-evaluation by their child's physician.Parents also need to be educated aboutthe lack of proven efficacy and the potentialadverse effects of available cold remedies.Saline nose drops and adequate fluidsas well as antipyretics for bothersomefever may provide limited symptomatic relief,but time is still the only known cure.

The patient had been born at term following an uncomplicated pregnancy and labor. Her growth and development were appropriate. Her immunizations were up-to-date. At about 1 year of age, she began to have "wheezing" episodes. Moderate persis- tent asthma was diagnosed, and treatment with fluticasone and inhaled albuterol was initiated.

The patient had been born at term following an uncomplicated pregnancy and labor. Her growth and development were appropriate. Her immunizations were up-to-date. At about 1 year of age, she began to have "wheezing" episodes. Moderate persistent asthma was diagnosed, and treatment with fluticasone and inhaled albuterol was initiated.

If you are a regular reader of this journal, you've probably enjoyed articles on a number of topics that were written by Dr Linda S. Nield. I'm pleased to announce that Dr Nield has recently joined the editorial board of Consultant For Pediatricians, and I would like to extend to her a warm welcome.

With the banning of peanut butter and jelly from some school cafeterias, peanut allergies have become a popular topic in the media and the public. Discussions often include references to an increasing prevalence of allergies, as well as to an earlier emergence of those allergies in children.

1. The chest radiographs (Figure 1) of a 9-year-old child reflect the classic findings of a particular disease. Among other findings, the size of the patient's heart is_____?

The National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program (NAEPP) released its Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma--Full Report, in August 2007.1 The EPR-3 is the fourth iteration of the guidelines, which were first released in 1991 (EPR-1), revised in 1997 (EPR-2), and partially revised in 2002 (Update on Selected Topics). For the first time since their inception, the guidelines include separate recommendations specific to children aged 0 to 4 years and 5 to 11 years. Table 1 highlights the key differences between the 1997 EPR-2 guidelines and the 2007 EPR-3 guidelines regarding treatment of pediatric asthma.

1. The chest radiographs (Figure 1) of a 9-year-old child reflect the classic findings of a particular disease. Among other findings, the size of the patient's heart is_____? A. Enlarged. B. Small to normal. C. Consistent with early failure. 2. If you were to see calcifications in the abdomen (none are present in this case), they would probably be caused by which of the following? A. Previous adrenal hemorrhage.  B. Gallstones.  C. Splenic granulomas.  3. Is there evidence of hyperinflation? A. Yes . B. No. 4. Do you see acute findings?  A. Yes.  B. No.   C. Cannot be determined. 5. Which of the following organisms are common culprits in this condition? A. Pseudomonas aeruginosa. B. Burkholderia cepacia.  C. Staphylococcus aureus.  D. All of the above, and then some.

If you are a regular reader of this journal, you've probablyenjoyed articles on a number of topics that werewritten by Dr Linda S. Nield. I'm pleased to announcethat Dr Nield has recently joined the editorial boardof Consultant For Pediatricians, and I would like toextend to her a warm welcome.

Three-year-old boy limping on right foot after an unwitnessed fall from trampoline the day before. Pain controlled with ibuprofen. No history of chronic diseases or routine medication use.

With the banning of peanut butter and jelly from someschool cafeterias, peanut allergies have become a populartopic in the media and the public. Discussions ofteninclude references to an increasing prevalence ofallergies, as well as to an earlier emergence of thoseallergies in children.

ABSTRACT: Young children with suspected foreign-body aspirations are common in emergency departments and primary care offices. A "sentinel event" consisting of a sudden onset of choking, gasping, gagging, wheezing, stridor, difficulty in breathing, change in phonation, or difficulty in swallowing may indicate aspiration. In many cases, the diagnosis is missed because the child is asymptomatic on presentation. Normal physical findings can be misleading or the child may have nonspecific symptoms that are initially misdiagnosed as asthma, croup, bronchitis, or pneumonia. Except for endoscopy, most routine diagnostic studies can be falsely reassuring when results are normal. The literature is reviewed here and recommendations are made about how to evaluate and safely manage children with suspected foreign-body aspiration.