All of the following are features of chronic non-specific (toddler's) diarrhea of childhood, except:
Correct Answer E:
Toddler's diarrhea also known as chronic nonspecific diarrhea of childhood, this is a perplexing condition for parents and doctors alike. It is defined as a diarrhea that lasts for more than two weeks, usually consists of 5-10 watery stools per day (often with undigested food particles in the stool, in a child between about 6 months to 4 or 5 years old, who is growing and developing normally and otherwise seems healthy, there is no detectable medical cause for the diarrhea such as infection, food malabsorption or allergy.
The child's diet must be evaluated. Fluid intake may play a factor. Studies have shown a link between excessive fluid consumption and toddlers diarrhea, as well as high carbohydrate, low fat diets. Excess fruit juice intake - especially apple juice - is often the cause of mysterious diarrhea (apple juice contains sorbitol, the "active ingredient" in prunes). If the child is being given any natural remedies or health foods, these need to be mentioned to the doctor and probably stopped to see if there is an improvement in the diarrhea.
Treatment is mostly dietary manipulation. Carbohydrates, especially fruit juices, are reduced and fat increased to 35-40% of the total calories. High fiber foods such as beans, fruit, breads, and cereals should be encouraged. Antidiarrheal medications are probably ok for very short periods of worsening symptoms, but should not be used for very long, nor very often.
A 2-year-old toddler is brought to the emergency department eight hours after accidental ingestion of gasoline. On examination she is afebrile and has no respiratory distress. Chest x-ray is normal.
Which one of the following is the most appropriate intervention?
There is no antidote for gasoline poisoning. Treatment consists of support of cardiovascular and respiratory functions. In cases of ingestion, do not induce emesis or use gastric lavage and do not administer activated charcoal. Gasoline is poorly absorbed from the stomach. Catharsis with magnesium or sodium sulfate is acceptable. If spontaneous vomiting occurs, watch for signs of pulmonary aspiration.
All symptomatic patients should have a chest X-ray taken no sooner than two hours post ingestion, and should be observed in the emergency department for a period of six hours. The patient may be discharged with observation at home if asymptomatic throughout and X-ray is negative, as in this patient.
In the presence of a positive two-hour X-ray, the patient should be admitted for monitoring of blood gases, repeat chest X-rays, and respiratory support if required. This child has no respiratory distress and Chest X-ray did not show any abnormalities, therefore, he should be discharged home (choice E).
→ Steroids (choice A) and Antibiotic prophylaxis (choice B) are of no proven benefit in gasoline and other hydrocarbon poisoning.
→ Induce vomiting to empty the stomach (choice C) is incorrect. Gasoline is poorly absorbed from the stomach and emesis should not be induced. Decontamination should focus on removing any remaining hydrocarbon that might be on the clothes or skin, in the correct clinical setting.
→ Admit to ward for observation (choice D) is unnecessary for a patient whose condition is considered stable in the emergency room.
A 2-month-old girl, with a large ventricular septal defect, has moderate bronchiolitis due to respiratory syncytial virus.
Which one of the following treatments is considered principal therapy?
Correct Answer C:
Most children with bronchiolitis recover at home in 3 to 5 days. During the illness, frequent small feedings of clear fluids may be given. Increasing difficulty in breathing, bluish skin discoloration, fatigue, and dehydration indicate that the child should be hospitalized. Children with congenital heart or lung disease or an impaired immune system may be hospitalized sooner and are far more likely to become quite ill from bronchiolitis. With proper care, the chance of dying of bronchiolitis is low, even for children who need to be hospitalized.
In the hospital, oxygen levels are monitored with a sensor on a finger, toe, or an earlobe, and oxygen is given by an oxygen tent or face mask. Among numerous medications and interventions used to treat bronchiolitis, thus far, only oxygen appreciably improves the condition of young children. Therefore, therapy is directed toward symptomatic relief and maintenance of hydration and oxygenation.
→ Nebulized racemic epinephrine (choice A) shows significant improvement in wheezing and respiratory distress but does not reduce the need of oxygen therapy and is considered to be as effective as nasal decongestants. It s not principal therapy for bronchiolitis management in infants.
→ Bronchodilator therapy with salbutamol (choice B) to relax bronchial smooth muscle, though common, is not supported as routine practice by convincing evidence.
→ The antiviral drug ribavirin (choice D) is incorrect. Although ribavirin has the potential to reduce days of mechanical ventilation and hospitalization, the data are insufficient to support its routine use to treat RSV infections, it is not recommended.
→ Intravenous hydration (choice E) is incorrect. Oral therapy is preferred. Parenteral therapy may be necessary in patients who are unable to take fluids by mouth or who have a respiratory rate higher than 70 breaths/min.
Key Point:
An otherwise healthy 1-year-old boy is brought to your office because of increased respiratory effort, wheezing, and rhinorrhea. He has no fever. On examination he is found to have an increased respiratory rate and mild retractions. A chest film shows no foreign body or infiltrates. Oxygen saturation is 94%.
Which of the following should be included in this patient's management?
Correct Answer A:
This presentation is consistent with bronchiolitis, which is a response to a viral respiratory infection. The Academy of Pediatrics guidelines for the management of bronchiolitis do not recommend routine use of any treatment, recommending instead that the choice be based on the specific needs of the child. Although inhaled bronchodilators are not used routinely for children with bronchiolitis, a one-time trial of albuterol (choice A) or epinephrine may be warranted for infants and children with bronchiolitis and severe disease (eg, nasal flaring; retractions; grunting; respiratory rate > 70 breaths per minute; dyspnea; or cyanosis) or respiratory failure. For patients in whom such a trial is warranted, albuterol 0.15 mg/kg (minimum 2.5 mg; maximum 5 mg) diluted in 2.5 to 3 mL normal (0.9%) saline and administered over 5 to 15 minutes or four to six puffs via a metered dose inhaler with spacer and face mask is suggested. If the child responds to a trial of albuterol, then treatment can be continued; otherwise, evidence shows no benefit.
→ Ribavirin (choice B) should not routinely be used.
→ Oxygen (choice C) is indicated if the saturation is less than 90%.
→ Antibiotics (choice D) are indicated for signs of bacterial infection.
→ Corticosteroids (choice E) have not been shown to be of benefit.
A previously healthy 18-month-old male is brought to your office with a 2-day history of cough and fever. On examination the child has a temperature of 38.3°C (100.9°F), a respiratory rate of 30/min, and mild retractions and mild wheezes bilaterally. Oxygen saturation is 90%.
The most appropriate initial management would be:
For patients with bronchiolitis, evidence supports a trial of an inhaled bronchodilator, albuterol, or epinephrine, with treatment continued only if the initial dose proves beneficial. There is no evidence to support the use of antibiotics unless another associated infection is present (e.g., otitis media). Neither corticosteroids nor postural drainage has been found to be helpful.
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