Pediatric Primary Care Case Studies (95 page)

Other potentially helpful management interventions that might be considered in select cases include:

•   Use of physical exercise/training to increase muscular tone. Exercise prompts fitness, which counteracts neurocardiogenic syncope but can make symptoms worse initially. Therefore, it should be done cautiously at first.

•   Use of waist-high support hose to prevent pooling (knee-high hose may not work well).

The coach was also worried about Emma and asked that you send him a note or call him regarding her condition.

What will you tell the coach?

With the family’s approval, the healthcare provider can tell the coach and also write him a note stating Emma’s ECG findings are normal and that she does not have a cardiac etiology to this fainting spell. By Emma taking the precautions listed previously, she will decrease the possibility of a similar event. However, if Emma and the coach do not follow the precautions, it is remotely possible that she may have another syncopal event.

Suggest that the coach and athletic trainers consider administering the 2004 American Academy of Pediatrics Pre-sports Participation Form as a part of their screening procedure for students applying for school sports.

Key Points from This Case

1. Syncope is a sudden, brief loss of consciousness associated with loss of postural tone from which recovery is spontaneous.

2. Syncope in children is most often benign. However, syncope can also occur as the result of more serious cardiac disease with the potential for sudden death.

3. A complete history and physical examination and ECG findings typically identify children with a life-threatening cause of syncope.

4. A patient with a normal ECG has a low likelihood of arrhythmia as a cause of syncope (Kapoor, 2000).

5. The use of additional testing, beyond history, physical examination, and ECG, can be avoided in many patients with transient loss of consciousness (van Dijk et al., 2008).

6. Syncope that occurs during physical exertion is very concerning for a cardiac etiology, whereas syncope after exertion may occur with vaso-vagal syncope or cardiac conditions (Driscoll et al., 1997).

7. In some studies, echocardiograms, chest radiographs, cardiac catheter-izations, electrophysiology studies, tilt table test, and serum evaluations were found to be neither cost-effective nor diagnostic.

8. The responsibility of the primary care provider is to quickly identify the child or adolescent who needs a referral to the appropriate specialist. For example, when a cardiac etiology is identified, such as a structural heart disease or arrhythmias, a cardiology consult should be made for further evaluation and management. Similarly, when a neurologic etiology is identified, such as a seizure or head trauma, a neurologic consult should be made for further evaluation and management.

9. An algorithmic approach to syncope is recommended.

REFERENCES

Atkins, D., Hanusa, B., Sefcik, T., & Kapoor, W. (1991). Syncope and orthostatic hypotension.
American Journal of Medicine, 91
, 179–185.

Driscoll, D. J., Jacobsen, S. J., Porter, C. J., & Wollan, P. C. (1997). Syncope in children and adolescents.
Journal of the American College of Cardiology, 29
, 1039–1045.

Gillette, P. C., & Garson, A. Jr. (1992). Sudden cardiac death in the pediatric population.
Circulation, 85
, (1 Suppl): 164–169. Review.

Kapoor, W. N. (2000). Syncope.
New England Journal of Medicine, 343
, 1856–1862.

Kapoor, W. N., Peterson, J. R., Wieand, H. S., & Karpf, M. (1987). Diagnostic and prognostic implications of recurrences in patients with syncope.
American Journal of Medicine, 83
, 700–708.

Lewis, D. A., & Dhala, A. (1999). Syncope in the pediatric patient. The cardiologist’s perspective.
Pediatric Clinics of North America, 46
, 205–219.

Maron, B. J., Shirani, J., Poliac, L. C., Mathenge, R., Roberts, W. C., & Meuller, F. O. (1996). Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles.
Journal of the American Medical Association, 276
, 199–204.

Massin, M. M., Bourguignont, A., Coremans, C., Comte, L. Lepage, P., & Gerard, P. (2004). Syncope in pediatric patients presenting to an emergency department.
Journal of Pediatrics, 145
, 223–228.

Mathias, C. J., Deguchi, K., & Schatz, I. (2001). Observations on recurrent syncope and presyncope in 641 patients.
Lancet, 357
, 348–353.

Moss, A. J. (2003). Long QT syndrome.
Journal of the American Medical Association, 289
, 2041–2044.

Reuter, D., & Brownstein, D. (2002). Common emergent pediatric neurologic problems.
Emergency Medicine Clinics of North America, 20
, 155–176.

Ritter, S., Tani, L. Y., Etheridge, S. P., Williams, R. V., Craig, J. E., Minich, L. L. (2000). What is the yield of screening echocardiography in pediatric syncope?
Pediatrics, 105
, E58.

Steinberg, L. A., & Knilans, T. K. (2005). Syncope in children: diagnostic tests have a high cost and low yield.
Journal of Pediatrics, 146(3)
, 335–338.

van Dijk N., Boer, K. R., Colman, N., Bakker, A., Stam, J., van Grieken, J. J., et al. (2008). High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment Study.
Journal of Cardiovascular Electrophysiology, 19
, 48–55.

Chapter 24

The Child Presenting with Cough

Jennifer Newcombe

Respiratory problems are the leading cause of illness in children. Viral infections are the primary causative agents and seasonal variations are noted. Children with respiratory infections are commonly seen in the primary care setting and are brought in by parents who are concerned about relieving their child’s associated respiratory symptoms. Children typically do well with outpatient treatment. However, it is important to recognize circumstances that warrant hospitalization.

Educational Objectives

1.   Explain the findings of pneumonia typically found upon physical examination.

2.   List differential diagnoses for pneumonia.

3.   Outline the antibiotics used to treat
Mycoplasma pneumoniae
in an outpatient setting.

4.   Describe circumstances that warrant hospitalization for an infant or child with pneumonia.

   Case Presentation and Discussion

Mary Dixon, a previously healthy 5-year-old white female, is brought to your clinic by her father because of difficulty breathing for 1 day. Two days prior she developed a runny nose, cough, and low grade fever; her maximum temperature was 101°F (38.3°C) yesterday. Her temperature this morning was 103°F (39.4°C) and she was breathing fast, working hard to breathe. Her mother was concerned and had Mary’s father bring her in to be seen because she had to go to work. Mary’s appetite is fair. She takes liquids well, but her solid intake has decreased. Mary’s father denies that his daughter has had any nausea, vomiting, or diarrhea. Her activity level is good. She has had no recent contact with others with respiratory or other illnesses and does not attend daycare or preschool. Her past medical history is negative for allergies or asthma. She is not taking medications other than Tylenol (acetaminophen). Her last dose of Tylenol was yesterday evening before bedtime. Her immunizations are up to date by record review, and she has no known drug allergies, hospitalizations, or surgeries.

What other questions will you ask her father related to her illness?

The main symptoms of pneumonia are fever and cough; although children with these two symptoms don’t necessarily have pneumonia, clinicians should always consider the possibility of pneumonia if these symptoms are present (Durbin & Stille, 2008). A typical history should focus on the duration of illness, respiratory symptoms (i.e., quality of cough, wheezing, difficulty with breathing), and extra respiratory symptoms such as fever, headache, sore throat, lethargy, or rash (Durbin & Stille).

Her father states her cough is wet sounding, productive, and is persistent throughout the day. He describes the sputum as yellowish in color. Her father said Mary complained of a mild headache earlier this morning but said she didn’t have a sore throat or lethargy.

Pathophysiology of Pneumonia

Pneumonia is a lower respiratory tract infection that is associated with consolidation of the alveolar space and lung parenchyma involvement. It usually follows an upper respiratory tract infection that permits invasion of the lower respiratory tract by bacteria, viruses, or other pathogens. This invasion triggers the immune response to produce inflammation (Jenson & Baltimore, 2006). Agents that cause lower respiratory tract infections are usually transmitted by droplets spread directly from close personal contact or indirectly by contaminated fomites (Durbin & Stille, 2008).
S. pneumoniae
is responsible for 90% of childhood bacterial pneumonias and is common in all age groups. Mycoplasma pneumonia is common after 5 years of age (Brady, 2009). The incubation period after exposure for mycoplasma pneumonia averages 3 weeks (Pickering, Baker, Long, & McMillan, 2006). If the normal host defense mechanisms does not function properly and effectively, pneumonia can occur. The normal respiratory defense functions include: nasopharyngeal air filtration; laryngeal protection of the airway to prevent aspiration of oral and gastric fluid; mucociliary clearing of particles and pathogens from the upper and lower airways; a strong defensive cough reflex; anatomically correct and unobstructed airway drainage; normal immune function at both the humoral and cellular levels; and normal innate biochemical and redox-based host defense mechanism (Gaston, 2002). However, defects in the host defenses increase the risk of pneumonia.

The infectious agents that commonly cause pneumonia vary by age of the child and setting in which the infection is acquired (community or nosocomial), along with the presence of any underlying disease. (See
Table 24-1
.) The most common infecting agents by age are respiratory syncytial virus (RSV) in infants; RSV, parainfluenza viruses, influenza viruses, adenoviruses in children younger than 5 years old; and
M. pneumonia
and
S. pneumoniae
in children older than five (Jensen & Baltimore, 2006).

Complications that may result from acute bacterial pneumonia include pleuritis (inflammation of the pleura), pleural effusion, pyothorax (pus in the
pleural cavity), empyema (organized pyothorax with fibrous walls), and bacteremia (Jenson & Baltimore, 2006).

Epidemiology of Pneumonia

According to the World Health Organization, there are 150.7 million cases of pneumonia every year in children younger than 5 years (Rudan et al., 2004). In the United States, the annual incidence of pneumonia in children younger than 5 years is estimated to be 34 to 40 cases per 1,000, while the incidence decreases to 7 cases per 1,000 in adolescents 12 to 15 years of age. The mortality rate in developed countries remains low, at less than 1 per 1,000 per year; however, in third world countries, respiratory tract infections are more prevalent and severe. Pneumonia in these countries accounts for more than 4 million deaths annually (Durbin & Stille, 2008).