Which of the following is usually an acute cause rather than chronic cause of diarrhea in a child?
Correct Answer A:
Acute diarrhea is most likely infectious, especially if onset is sudden or accompanied by vomiting, bloody stools, fever, anorexia, or listlessness. Diagnosis is clinical, and treatment is supportive until the condition resolves spontaneously.
Chronic diarrhea is usually more significant. Causes include gluten-induced enteropathy (celiac disease), cystic fibrosis, sugar malabsorption, and allergic gastroenteropathy. Inflammatory bowel disease and some infections (eg, with Giardia) can also cause chronic diarrhea.
An outbreak of pediatric diarrhea has swept your community. You evaluate a 20-month-old male who developed diarrhea yesterday. He is still breastfed. He is alert, his mucous membranes are moist, and his skin turgor is good. He passes a liquid stool in your office.
Which one of the following would be the best advice with regard to his diet?
Correct Answer B:
Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be given. Breastfeeding or regular formula should be continued.
Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables are well tolerated. Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided because the osmotic load can worsen the diarrhea. Fatty foods should be avoided as well. The BRAT diet has not been shown to be effective.
A child presents with bilateral shin pain. Which of the following suggests that this is not growing pains?
Correct Answer E:
Growing pains are a common complaint of adolescents. Usually found around the ages of 9 to 14, growing pains are the result of the rapid growth of these adolescents.
Several conditions such as Osgood-Schlatter Disease, and Sever's Disease, are types of growing pains. These conditions are caused by inflammation around sites where large tendons insert. These tendons pull on the growing bone (at the growth plate) and cause inflammation.
Growing pains are almost always seen in active youths, often while participating in sports. Growing pains are best treated with rest, stretching, and ice packs. If activities are causing significant growing pains, they should be avoided until the symptoms resolve. Growing pains are not usually associated with a limp.
A 6-year-old female is brought to your office for recurring limb pain. For the past two weeks she has complained of cramping pain in her thighs and calves, which has caused her to awaken at times. Massage and occasional acetaminophen help. In the morning the symptoms are gone and daily activity is unimpaired. Her physical examination is normal. On examination she has no inflammatory signs and no joint or muscle tenderness.
Which one of the following would be most appropriate at this point?
This patient is experiencing benign nocturnal pains of childhood, formerly called “growing pains.” These are cramping pains of the thigh, shin, and calf, and affect approximately 35% of children 4-6 years of age. The pain typically occurs in the evening or at night, may awaken the child from sleep, and disappears by morning. This classic presentation in the absence of other inflammatory or chronic signs and symptoms should reinforce the benign nature of this condition. Physical findings are normal, so in the absence of worrisome complaints or anatomic abnormalities no further diagnostic testing is required. Parents should be reassured that there are no long-term sequelae. If activity is impaired, the physical examination is abnormal, or any constitutional or systemic complaints are present, then further evaluation with additional testing is indicated, and may include an erythrocyte sedimentation rate, CBC, antinuclear antibody, or radiographs of affected bones or joints.
During a pre-participation examination of a 5-year-old male for summer soccer camp, his mother states that he frequently awakens during the night with complaints of cramping pain in both legs, and that he seems to experience this after a day of heavy physical activity. She says that he appears to drag his legs at times, but she has never noticed a definite limp. A physical examination of the hips, knees, ankles, and leg musculature is entirely normal.
Which one of the following would be the most appropriate next step in the evaluation and management of this patient?
Correct Answer D:
Benign nocturnal limb pains of childhood (growing pains) occur in as many as one-third of children, most often between 4 and 6 years of age. The etiology is unknown, but the course does not parallel pubescent growth, as would be expected if bone growth was the source of pain. The pain often awakens the child within hours of falling asleep following an active day. The pain is generally localized around the knees, most often in the shins and calves, but also may affect the thighs and the upper extremities. A characteristic history coupled with a normal physical examination will confirm the diagnosis. Reassurance that no additional tests or treatments are necessary and that the condition is self-limiting is the most appropriate response.
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