Asthma

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.

A 4-year-old girl presented with a sore throat, dysphagia, fever (temperature up to 40°C [104°F]), and a pruritic vesicular rash. On the first day of the illness, 4 days earlier, she was evaluated by her pediatrician who prescribed azithromycin for a presumed upper respiratory tract infection. About 2 days later, a papular rash developed on the abdomen and perioral skin; the fever had persisted, and the child's oral intake had decreased. The next day, the rash continued to spread, and the patient refused to take anything orally, including fluids. The mother thought that the rash was a hypersensitivity reaction to the antibiotic.

As a clinical immunologist with a special interest in vaccines, it is a pleasure to present this special issue of Consultant For Pediatricians. Vaccines are among the major achievements of modern medicine. Once common serious childhood illnesses, including tetanus, diphtheria, polio, mumps, and measles, are now rarely seen in this country. It is ironic, therefore, that with the precipitous decline in the incidence of many infectious diseases brought about by widespread vaccination--and the very recent availability of several new vaccines--many parents have been lulled into a false sense of security about the risk posed by the diseases these vaccines have been designed to prevent.

A 15-year-old girl was brought to the emergency department because of bilateral shoulder and hip pain associated with myalgia and fatigue. The symptoms had been present for 2 months and had increased in intensity over the past few days. The patient had systemic lupus erythematosus, asthma, and seizure disorder.

Transient tachypnea of the newborn (TTN) has traditionally been seen as a benign, self-limited disorder that occurs within a few hours of birth and resolves within 72 hours. For years, we have been telling parents that this innocent condition has no long-lasting effects and is nothing to be concerned about. According to a recent study in The Journal of Pediatrics, however, we may need to rethink that advice.

Severe disability and even death can result from the inappropriate diagnosis and treatment of a young child's wheezing, which is heterogeneous in its origins and expression. Consequently, a differential diagnosis is necessary to determine the cause and to develop an effective management strategy. Viral-induced wheeze, especially from respiratory syncytial virus (RSV), manifests as a bronchiolitis. Recent reports show that the cysteinyl leukotrienes are an important mediator of the airway effects of RSV infection and that leukotriene receptor antagonists reduce postrespiratory syncytial virus lung symptoms. Exercise-induced bronchoconstriction manifests as wheezing and can be treated or pretreated short-term with inhaled bronchodilators or cromolyn: long-term therapy includes inhaled corticosteroids and leukotriene receptor antagonists. Allergic rhinitis-associated wheeze may be the result of acute exposure to an allergen or simply from nasal dysfunction. Control of allergic rhinitis with intranasal steroids, antihistamines, or leukotriene receptor antagonists could relieve the wheezing. Asthma-associated wheeze requires long-term use of 1 or more daily controller medications. The primary goal is to navigate the child safely through the first episode of wheezing, consider the causes of the wheeze, and then evaluate the need for further therapy. All apparent causes of wheeze should be treated with the idea that if the apparent cause turns out not to be the actual cause, treatment can be safely discontinued.

ABSTRACT: Adolescent drivers with attention deficit hyperactivity disorder (ADHD) are more likely to be involved in--and to die of--a driving accident than any other cause. The higher occurrence of driving mishaps is not surprising given that the core symptoms of ADHD are inattention, impulsivity, and hyperactivity. Safe driving habits can diminish the risk, however. The first step is to inform patients of the dangers of driving; the significance of adolescence, ADHD, and medication can be underscored in a written "agreement." Strategies to promote safer driving--especially optimally dosed long-acting stimulant medication taken 7 days a week--may be critical. A number of measures lead to safer driving by reducing potential distractions during driving (eg, setting the car radio before driving, no drinking or eating or cell phone use while driving, no teenage passengers in the car for the first 6 months of driving, and restricted night driving).

How old does a child need to be before we can count on the accuracy of his or her response?

One of the most common illnesses we treat in general pediatrics is asthma-often in children who have not yet entered their teen years. While we ask the parents what symptoms they have noticed in their child, we don’t always ask younger children directly. How reliable are their answers?

ABSTRACT: Because foreign-body aspiration can cause symptoms that mimic those of other respiratory conditions, a high index of suspicion is crucial in all children who have pneumonia, atelectasis, or wheezing with an atypical course--especially when these conditions are unresponsive to usual medical therapy. A history of choking can usually be elicited in a patient who has aspirated a foreign body: such a history should be sought when respiratory symptoms develop suddenly. However, the absence of a choking history does not rule out foreign-body aspiration. Moreover, patients may be asymptomatic initially. Normal radiographic findings do not exclude an aspirated foreign body. Bronchoscopy should be strongly considered when an aspirated foreign body is suspected, even if radiographic images show normal findings. Rigid bronchoscopy is the procedure of choice for removing aspirated foreign bodies in children. Prevention of foreign-body aspiration can be enhanced through anticipatory guidance of parents/caregivers and through continued product safety efforts.

Foreign-body aspiration is a relatively common occurrence in children. It may present as a life-threatening event that necessitates prompt removal of the aspirated material. However, the diagnosis may be delayed when the history is atypical, when parents fail to appreciate the significance of symptoms, or when clinical and radiologic findings are misleading or overlooked by the physician.

A 12-year-old girl presents with a 1-year history of itchy lesions on her right leg. The lesions are worse during the winter. She has a history of atopic dermatitis and asthma.

Sixteen-year-old with a recurrent, painful, pruritic rash on right cheek and right eyelid. Current outbreak started 2 days earlier. The rash always appears in the same fashion and in the same location; it typically lasts a few days and resolves spontaneously.

The patient is a healthy 5-year-old boy who typically awakens 90 minutes after falling asleep. His parents find him screaming, sweaty, and standing up wide-eyed in bed (Figure A). These episodes occur 3 or 4 times a week. He is otherwise a happy, well-adjusted child who attends kindergarten. He has an older sibling with whom he gets along well. There have been no changes in the family.

A 17-year-old Asian male with no significant medical history presented to the emergency department (ED) with acute shortness of breath and associated left-sided chest pain. Symptoms began while the patient was at rest: the pain was sharp and worsened with inspiration. He denied a history of fever, trauma, cough, or any other constitutional complaints.

Chest pain in children evokes anxiety in patients and their parents--and prompts frequent visits to the pediatrician's office, urgent care facility, or emergency department (ED). In a prospective study, Selbst and colleagues reported that chest pain accounted for 6 in 1000 visits to an urban pediatric ED.

For several months, a 12-year-old boy has been bothered by intermittent pruritus of the feet. He is very active in sports all year, and his feet tend to perspire heavily. He has a family history of seasonal allergies. He says that the rash worsened after he used an over-the-counter hydrocortisone cream.

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed bio-behavioral disorder of childhood. It occurs in 6% to 9% of children--about the same prevalence as childhood asthma. It is also one of the most controversial diagnoses in children; parents are often perplexed about whether ADHD is underdiagnosed or overdiagnosed, or undertreated or overtreated. A good deal of this confusion stems from the fact that there are no laboratory tests, imaging studies, or psychological testing profiles that can be used to make the diagnosis.

The prevalence and incidence of sinus infection, or sinusitis, is increasing and has been estimated to affect 31 million persons in the United States each year. It is one of the most common reasons why patients seek a physician's care. If left untreated, sinusitis can cause significant physical symptoms and can negatively affect quality of life by substantially impairing the daily functioning of sufferers. For children, this can mean learning difficulties at school and for adults, a loss of efficiency at work.

What evidence is there that acetaminophen can cause or exacerbate asthma?

The use of analgesics, specifically acetaminophen, has been proposed as one of the mechanisms for the rise in asthma prevalence in the past 30 to 40 years.

The patient, a 13-year-old girl, was concerned about the development of a very itchy, painful, papular rash on her hands and feet. She had been previously well and had no history of illness other than a minor upper respiratory tract infection 2 weeks earlier. The distribution of lesions and the severe pruritus initially suggested scabies, which was treated with 5% permethrin cream. The rash did not improve with applications of this medication, however, and the patient returned the following day for care. She had no oral lesions but complained of mildly painful, nonswollen joints.

Until very recently, when it came to chronic cough, children were to be treated like little adults. In its 1998 guidelines on cough, the American College of Chest Physicians (ACCP) stated that "the approach to managing chronic cough in children is similar to the approach in adults."