e’_1�

CONTENTS

ARTICLES

443 What’s New in CardiologyI’!. Scott Ba/dti’in

448 Family-focused Behavioral Pediatrics:Clinical Techniques for Primary CareWi//ian, L. Coleinaii aiid Barbara J. Howard

458 The Child Who Has a LimpT/zonias’ S. Re,,s’/,att’

466 Preparing for Pediatric EmergenciesJanu’s Seidel

473 Consultation with the Specialist:Corrosive IngestionsFrederick H. Lovejov, Jr and A/a�z D. Woo/f

477 Consultation with the Specialist:UveitisDai’u/ M. Siege/

IN BRIEF

456 Hodgkin Disease474 Erythema Infectiosum (Fifth Disease)475 Choanal Atresia

INDEXES

480 Cumulative Author Index484 Cumulative Subject Index

COVER

Working in the medium of batik, Paul Nzalamba creates images that aredrawn from his native country, Uganda, and that reflect the strength,struggle, and beauty of all people, especially children and adolescents. Wechose to use his “At Play” (1988) to show a modern, indigenous artist’swork that illustrates the color and joy of such artists. Mr. Nzalamba’sworks are on display at his studio in Los Angeles, California. Reproduced

with permission.

ANSWER KEY

1. 1); 2. A; 3. A; 4. D; 5. D; 6. B; 7. II; 8. E; 9. C; 10. B; 11. C; 12. B; 13. B

The printing and production

of Pediatrics in Review ismade possible, in part, by

an educational grant from

Ross Products Division,

Abbott Laboratories.

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Printed in USA

Pediatrics in ReviewVol. 16 No. 12

December 1995

EDITOR

Robert J. Haggerty

University of Rochester

School of Medicine and Dentistry

Rochester, NY

Editorial Office:

Department of Pediatrics

University of Rochester

School of Medicine and Dentistry

601 Elmwood Ave. Box 777

Rochester, NY 14642

ASSOCIATE EDITOR

Lawrence F. Nazarian

Panorama Pediatric Group

Rochester, NY

CONSULTING EDITOR

Evan Charney, Worcester, MA

EDITOR, IN BRIEF

Steven P. Shelov, Bronx, NY

ASSOCIATE EDITOR, IN BRIEF

Henry M. Adam, Bronx, NY

MANAGING EDITOR

Martha H. Saltzman, Elk Grove Village, IL

EDITORIAL CONSULTANT

Victor C. Vaughan, Ill, Stanford, CA

EDITORIAL BOARD

Russell W. Chesney, Memphis, TN

Peggy Copple, Tucson, AZ

Richard B. Goldbloom, Halifax, NS

John L. Green, Rochester, NY

Walter Huurman, Omaha, NE

Robert L. Johnson, Newark, NJ

Kathi Kemper, Seattle, WA

John T. McBride, Rochester, NY

Lawrence C. Pakula, Timonium, MD

Ronald L. Poland, Hershey, PA

James E. Rasmussen, Ann Arbor, Ml

Kenneth B. Roberts, Worcester, MA

Bradley M. Rodgers, Charlottesville, VA

Allen W. Root, Tampa, FL

Richard H. Sills, Newark, NJ

Frank R. Sinatra, Los Angeles, CA

Laurie J. Smith, Washington, DC

Martin T. Stein, LaJolla, CA

William B. Strong, Augusta, GA

Jon Tingelstad, Greenville, NC

Vernon T. Tolo, Los Angeles, CA

Terry Yamauchi, Little Rock, AR

EDITORIAL ASSISTANT

Sydney Sutherland

PUBLISHERAmerican Academy of Pediatrics

0. J. Sahler, MD, Director

Department of Education

Jo A. Largent, Director

Division of Medical Journals

Deborah Kuhlman, Copy Editor

PEDIATRICS IN REVIEW (ISSN 0191-9601) is owned

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P0 Box 927, Elk Grove, IL 60009-0927.Statements and opinions expressed in Pediatncs

in Review are those of the authors and not neces-

sarily those of the American Academy of Pediatricsor its Committees. Recommendations included in

this publication do not indicate an exclusive course

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456 Pediatrics in Review Vol. 16 No. 12 December /995

PIR QUIZ

I. Which of the following functions in

the tIeld of children’s behavior is

served best by the primary carepediatrician?

A. Advising on complex, serious

behavioral problems such as

starting fires.

B. Diagnosing psychiatric problems,

especially those involving family

therapy.

C. Evaluating hearing, includingacoustic impedance testing.

D. Screening for family psycho-

social dysfunction. which may

affect a child’s behavior ordevelopment adversely.

2. Taking a history for child behavioral

problems is accomplished best with:A. All of the significant people in

the child’s home.B. The child alone.C. The father alone.

D. The mother alone.E. The mother and father without

the child present.

3. The best approach to generating so-

lutions to a child’s behavior prob-

lems is for:

A. The pediatrician and family tonegotiate goals and homeworktogether.

B. The pediatrician to encourage theparents to make exceptions forthe child when the child breakslimits.

C. The pediatrician to establish thetreatment goal.

D. The pediatrician to instruct the

parents to record each time thechild misbehaves.

E. The pediatrician to tell the family

that only a miracle will help their

child.

4. The best treatment goals for behav-ioral problems are:A. Based on changing the environ-

ment rather than the behavior.

B. General.C. Long-range and all-encompass-

ing.

D. Specific. achievable, and measur-able.

E. The same for all families.

IN BRIEF

Hodgkin Disease

When Is Lymph Node Biopsy Indicated in

Children with Enlarged Peripheral

Nodes? Knight Pi, Mulne AF, Vassy LE.Pediatrics. l982;69:39 1-396

Hodgkin’s Disease in the Very Young.

Cleary SF, Link MP, Donaldson 55. J

Radiat Oncol Biol Phys. 1993:28:77-83Hodgkin’s Disease. Donaldson 55, Link MP.

Pediatr Clin North Am. I 991:38:457-473

Hodgkin Disease: Clinical Utility of CT in

Initial Staging and Treatment. Hopper

KD, Diehl LF, Lesar M, et al. Radiology.1988:169:17-22

Septicemia and Meningitis in Children

Splenectomized for Hodgkin’s Disease.

Chilcote RR, Baehner RL, Hammond D.

N Engl J Med. 1976;285:798-8(X)

Hazard of Overwhelming Infection After

Splenectomy in Childhood. Eraklis Al,

Kevy SV, Diamond LK, et al. N EngI JMed. I967;276: I225-I 229

Controversies in the Management of Early

Stage Hodgkin’s Disease. Mauch PM.

Blood. l994;83:318-329

Lymph node enlargement is a fre-

quent finding on the physical exami-

nation of children, and it is important

for the pediatrician to recognize the

differences between lymphadenopathyrelated to infection and lymphade-nopathy that results from Hodgkin

disease.A lymph node involved with

Hodgkin disease usually is not pain-ful or tender; infected nodes charac-teristically are. The nodes of Hodgkindisease are firm and rubbery, but nothard (‘ ‘like a rock’ ‘). They tend to befixed, to be minimally moveable if atall, but they may change in size overweeks and months, often becominglarger and smaller prior to diagnosis.Enlarged nodes in the upper half ofthe neck, in the anterior and posteriorchains, and in the submandibular re-gion generally are associated withrespiratory tract infections in chil-dren; only rarely are cases of

Hodgkin disease found here. Lowercervical and supraclavicular nodesare much more likely to show in-volvement with Hodgkin disease be-cause of the anatomy of lymphaticdrainage. The right lymphatic ducttransports lymph from the chest and

mediastinum to the right lower neck;the thoracic duct carries fluid from

abdominal lymph nodes to the leftlower neck.

In the absence of an identifiablerespiratory tract infection, an upper

cervical lymph node should be biop-sied if enlargement has not resolved

within 3 to 6 weeks. If they are firm,

lower cervical and supraclavicular

nodes should be biopsied without

delay and handled by the pathologistas potentially involved with Hodgkin

disease.

Knight noted that of 239 lymphnode biopsies in children younger

than 16 years of age, 52% showed

reactive hyperplasia; of the 13% thatwere malignant, two thirds revealed

Hodgkin disease. When matched to

the site of the lymphadenopathy, I 1of 23 supraclavicular and lower neck

nodes were involved with Hodgkindisease (48%). The diagnostic yield

of supraclavicular lymph node biop-sies in children and adults was diag-

nostic in 90% of biopsies, axillarynodes in 63%, and inguinal nodes in

39%. The age group least likely to

have diagnostic nodes was between

2 1 and 40 years old. WheneverHodgkin disease is a consideration,

the biopsy should be excisional toassure the pathologist a tissue sampleadequate for determining the archi-

tecture of the node and identifyingpathognomonic Reed-Sternberg cells.

More than 75% of patients who

have Hodgkin disease have unilateralor bilateral lymphadenopathy low in

the neck; about 30% have involve-ment of axillary nodes. Inguinal

lymph node enlargement, so commonamong children, very infrequentlysignals the presence of Hodgkin dis-ease. Pharyngeal, brachial, epitroch-

lear, or popliteal node involvement israre, but persistent unilateral tonsillarenlargement should be evaluated bybiopsy.

Children who have Hodgkin dis-ease may experience weight loss,

fevers, and night sweats (classic “B”

symptoms); 20% to 35% of childrenhave one or more of these symptomsat the time of presentation. The com-bination of lymphadenopathy and anysymptoms suspicious of Hodgkin dis-ease should accelerate the decision to

biopsy the affected node(s).

Chest radiography, which is inex-

pensive and easily performed, also

plays an important role in the evalua-tion of children when Hodgkin dis-ease becomes a consideration. Wid-

ening of the mediastinum, perihilar

lymph node enlargement, or pulmo-

TABLE 4. Intra-abdominalCauses of Limping

#{149}Appendicitis#{149}Pelvic abscess

#{149}Psoas abscess#{149}Renal problems#{149}Retroperitoneal neoplasms

#{149}Hernias

PIR QUIZ

5. Mike is an 8-year-old boy who has

had a limp and has complained ofpain in his left hip for 2 weeks. He

has no history of trauma or recentinfection. Examination shows guard-

ing of the muscles crossing the left

hip joint and limitation of active and

passive hip joint motion. You sus-

pect he may have transient synovitis

of the hip. Your diagnosis can be

made most readily on the basis of:A. Aspiration of the hip joint.

B. Effusion in the hip joint on

ultrasonography.

C. Elevation of the erythrocyte sedi-

mentation rate.

D. Exclusion of other hip problems.E. Intensity of hip pain.

7. Bill is a 12-year-old obese male who

has complained of slight pain in the

right thigh and knee for 6 weeks.

His complaints are made worse by

running. He has had a mild limp. Hehas no history of recent infection ortrauma. Physical examination shows

a slight decrease in internal rotation

of the right hip. A radiograph shows

metaphyseal osteopenia. Klein’s line

intersects less of the femoral head

on the right than on the left. The

most likely diagnosis is:

A. Osteomyelitis.

B. Perthes disease.

C. Septic arthritis.

D. Slipped capital femoral

epiphysis.

E. Transient synovitis.6. Harry is a 5-year-old boy who has

had a limp and a painful right hipfor I month. He has no history ofrecent infection, and his parents do

not recall any significant trauma. A

radiograph shows apparent wideningof the medial joint space and mild

flattening of the femoral head. Phys-

ical examination reveals some but-

tock atrophy. decreased internal rota-

tion of the hip, and joint tenderness

on palpation. The most likely diag-nosis is:

A. Osteomyelitis.

B. Perthes disease.

C. Septic arthritis.

D. Slipped capital femoral

epiphysis.

E. Transient synovitis.

8. Beth is a 4-year-old girl who has a

recent, sudden onset of pain in her

right knee. She has a slight limp.Her temperature is elevated slightly,

and she has been eating poorly. Herparents do not recall any trauma to

her leg. Physical examination reveals

slight redness and swelling of the

right knee, guarding on passive mo-

tion, and associated muscle spasm.

The most likely diagnosis is:A. Acute rheumatic fever.

B. Juvenile rheumatoid arthritis.

C. Lyme disease.

D. Osteomyelitis.

E. Septic arthritis.

Pediatrics in Review Vol. 16 No. 12 December 1995 465

#{149} ORTHOPEDICSLimp

lntra-abdominal ProblemsAlthough not commonly consideredto be a potential site for the cause oflimping in children, the abdomen

should be considered by the thoroughphysician, particularly when the

cause for limping has not been foundin the lower extremity or the spine

(Table 4). Appendicitis can irritate

the right iliopsoas muscle group, pro-ducing hip or thigh pain, musclespasm, hip flexion deformity, and

unilateral limping. A ruptured appen-dix or other cause of a pelvic ab-scess, such as erosive pelvic osteo-

myelitis, can irritate the obturator

internus muscle and produce pelvic

and/or hip pain. A psoas abscess usu-ally will cause substantial pain in thegroin and thigh. Unilateral renal dis-ease, infection, or urolithiasis can

produce back pain and spasm and,occasionally, limping. Retroperitonealtumors may involve motor and/or

sensory nerve fibers, resulting in uni-lateral weakness, leg pain, and limp-ing. Even painful hernias in the in-guinal or femoral canals can be anoccult cause of a limp.

ConclusionThe child who has a limp may have

a very serious problem until provenotherwise and the cause sometimes

will be difficultto determine, but

early diagnosis may avoid consider-able morbidity.

SUGGESTED READINGAronsson DD, Goldberg Mi. Kling Jr IF, Roy

DR. Developmental dysplasia of the hip.Pediatrics. l994;94:201-208

Clarke NMP, Cleak DK. Intervertebral lumbardisc prolapse in children and adolescents.

J Pediatr Orthop. 1983;3:202-208Gabuzda GM, Renshaw TS. Reduction of

congenital dislocation of the hip. J BoneJoint Surg. l992;74A:624-631

Hardinge K. The etiology of transient synovitis

of the hip in children. J Bone Joint Surg.

l970;52B: 100-107

Hensinger RN. Spondylolysis and spondy-

lolisthesis in children. American Academy ofOrthopaedic Surgeons Instructional Course

Lectures. l983;32: 132-149

Herndon WA, Knauer S. Sullivan JA.

Management of septic arthritis in children.

J Pediatr Orthop. 1986:6:576-578Micheli U, Fehlandt Jr AF. Stress fractures.

In: Letts RM, ed. Management of Pediatric

Fractures. New York, NY: Churchill

Livingstone; 1994

Nelson JD, Bucholz RW, Kusmiesz H.Benefits and risks of sequential parenteral-

oral cephalosporin therapy for suppurative

bone and joint infections. J Pediatr Orthop.

1982;2:255-262

Paley D. Current techniques of limb lengthen-

ing. J Pediatr Orthop. 1988:8:73-92

Peters W, Irving I, Letts RM. Long-term

effects of neonatal bone and joint infection

on adjacent growth plates. J Pediatr Orthop.

1992:12:806-810

Pettersson H, Gillespy I III, 1-lamlin Di.

Primary musculoskeletal tumors: exami-

nation with MR imaging compared with

conventional modalities. Radiology. 1987;164:237-241

Renshaw IS. Pediatric Orthopaedics.

Philadelphia. Penn: WB Saunders Co; 1986

Staheli LT. Fundamental.c of Pediatric

Orthopedics. New York, NY: Raven Press;

1992

Wells D, King ID, Roe IF, Kaufman FR.

Review of slipped capital femoral epiphysis

associated with endocrine disease. J Pediatr

Orthop. 1993:13:610-614

Wenger DR. Ward WT, Herring JA. Legg-

Calv#{233}-Perthesdisease. J Bone Joint Surg.

l99l ;73A:778-788

ries.

472 Pediatrics iii Review Vol. 16 No. 12 December 1995

EMERGENCY CAREOff Ics Emergencies

Durch iS, Lohr KN. Emergency Medical

Services for Children. Washington, DC:National Academy Press; 1993

Fleisher GR, Ludwig 5, eds. Textbook ofPediatric Emergency Medicine. Baltimore,Md: Williams and Wilkins; 1993

HaIler A, Johnson C, Luten R, Ct al, eds.

APLS: The Pediatric Emergency MedicalCourse. Elk Grovc Village. Ill: AmericanAcademy of Pediatrics; Dallas, Tex:

American College of Emergency Physicians;

I 993

Jay KM. Bartlett RH. Danet R, Allyn PA.

Burn cpidemiology: a basis for burn

prevention. J Trauma. I 977; 17:943-947Peter G, ed. 1994 Red Book Report of the

Conunittee O�l Infectious Disease. 23rd ed.Elk Grove Village. Ill: American Academy

of Pediatrics; 1994

Schweich PJ, DeAngelis C, Duggan AK.

Preparedness of practicing pediatricians to

manage emergencies. Pediatrics. 1991:88:

223-229

Singer I, Ludwig 5, eds. E�nergency Medical

Senices fir Children: The Role of the

Primary Care Provider. Elk Grove Village.

Ill: American Academy of Pediatrics; 1992

Tepas ii, DiScala C, Ramenofsky ML, Barlow

B. Mortality and head injury: the pediatric

perspective. J Pediatr Surg. l990;25:92-96

PIR QUIZ

9. A mother who has just left your

office returns, exclaiming franti-

cally that her 2-year-old sonchoked on a grape. The boy is cya-

notic, apprehensive, and struggling

to breathe. The most appropriatefirst step is to:A. Administer five back blows

between the scapulae.

B. Administer five chest thrusts.

C. Administer abdominal thrusts.

D. Conduct a blind sweep of themouth.

E. Perform a cricothyroidotomy.

10. A 3-year-old girl for whom youhave provided regular care since

birth is brought to your office with

a burn of the palm of her right

hand. On examination of the palm,

you note a 3.0 X 2.0 cm area ofgeneralized reddening with several

small, unroofed blisters. The fin-

gers are spared. The mother statesthat her daughter attempted to seize

a hot curling iron about 15 minutes

ago. The patient has no known al-

lergies. Which one of the following

interventions is required for opti-

mal management?A. Administration of prophylactic

antibiotics.

B. Application of silver sulfadia-

zine and a nonstick dressing.

C. Immediate referral to a hospital-

based thermal burn specialist.

D. Notification of child protective

services.

I I. An 18-month-old boy is brought toyour office by his mother after he

was found crying near an extension

cord. On examination, the boy is

alert but irritable. You note a I .5

cm wide semilunar, shallow ulcer-

ation of the lips at the right corner

of the mouth consistent with an

electrical burn. Which one of the

following interventions is required

for optimal management?

A. Administration of prophylacticantibiotics.

B. Application of silver sulfadia-

zine and a nonstick dressing.

C. Immediate referral to a hospital-

based electrical burn specialist.

D. Notification of child protective

services.

12. A 6-year-old boy is brought to

your office after striking his head

on the pavement when he tipped

over his bicycle. He was said to be

briefly groggy at the scene. He

vomited once earlier and now com-

plains of a mild generalii�d head-

ache. However, he is fully alert

(Glasgow Coma Score 15), recalls

events leading up to and following

the incident, and has otherwise un-

remarkable findings on general and

neurologic examinations. His

mother seems to be a competent

observer. The most appropriate nextstep is to:

A. Immobolize the neck and order

a cervical spine radiographic se-

B. Observe the patient at home

without further diagnostic test-

ing.

C. Obtain an immediate computed

tomographic scan of the head.

D. Obtain plain skull radiographs.

E. Order baseline complete blood

count and electrolyte levels.

13. A 17-year-old boy cut the bottom

of his left foot on a piece of glass

while walking barefoot on thebeach. The wound has jagged mar-

gins and requires copious irrigation

with normal saline to free it of

sand and debris. Review of his

medical history reveals completion

of a full five-shot diphtheria and

tetanus toxoids plus pertussis series

by time of entry to kindergarten,

but no subsequent immunizations.

The most appropriate step to pre-

vent tetanus in this circumstance is

to administer:

A. Diphtheria and tetanus toxoids

(DT)

B. Tetanus and diphtheria toxoid

(Td)

C. Tetanus immune globulin (hG)

D. TIG and bd