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
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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
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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