Asthma

A 4-year-old girl presented with a sore throat, dysphagia, fever (temperature up to 40°C [104°F]), and a pruritic vesicular rash. On the first day of the illness, 4 days earlier, she was evaluated by her pediatrician who prescribed azithromycin for a presumed upper respiratory tract infection. About 2 days later, a papular rash developed on the abdomen and perioral skin; the fever had persisted, and the child's oral intake had decreased. The next day, the rash continued to spread, and the patient refused to take anything orally, including fluids. The mother thought that the rash was a hypersensitivity reaction to the antibiotic.

As a clinical immunologist with a special interest in vaccines, it is a pleasure to present this special issue of Consultant For Pediatricians. Vaccines are among the major achievements of modern medicine. Once common serious childhood illnesses, including tetanus, diphtheria, polio, mumps, and measles, are now rarely seen in this country. It is ironic, therefore, that with the precipitous decline in the incidence of many infectious diseases brought about by widespread vaccination--and the very recent availability of several new vaccines--many parents have been lulled into a false sense of security about the risk posed by the diseases these vaccines have been designed to prevent.

A 15-year-old girl was brought to the emergency department because of bilateral shoulder and hip pain associated with myalgia and fatigue. The symptoms had been present for 2 months and had increased in intensity over the past few days. The patient had systemic lupus erythematosus, asthma, and seizure disorder.

Transient tachypnea of the newborn (TTN) has traditionally been seen as a benign, self-limited disorder that occurs within a few hours of birth and resolves within 72 hours. For years, we have been telling parents that this innocent condition has no long-lasting effects and is nothing to be concerned about. According to a recent study in The Journal of Pediatrics, however, we may need to rethink that advice.

Severe disability and even death can result from the inappropriate diagnosis and treatment of a young child's wheezing, which is heterogeneous in its origins and expression. Consequently, a differential diagnosis is necessary to determine the cause and to develop an effective management strategy. Viral-induced wheeze, especially from respiratory syncytial virus (RSV), manifests as a bronchiolitis. Recent reports show that the cysteinyl leukotrienes are an important mediator of the airway effects of RSV infection and that leukotriene receptor antagonists reduce postrespiratory syncytial virus lung symptoms. Exercise-induced bronchoconstriction manifests as wheezing and can be treated or pretreated short-term with inhaled bronchodilators or cromolyn: long-term therapy includes inhaled corticosteroids and leukotriene receptor antagonists. Allergic rhinitis-associated wheeze may be the result of acute exposure to an allergen or simply from nasal dysfunction. Control of allergic rhinitis with intranasal steroids, antihistamines, or leukotriene receptor antagonists could relieve the wheezing. Asthma-associated wheeze requires long-term use of 1 or more daily controller medications. The primary goal is to navigate the child safely through the first episode of wheezing, consider the causes of the wheeze, and then evaluate the need for further therapy. All apparent causes of wheeze should be treated with the idea that if the apparent cause turns out not to be the actual cause, treatment can be safely discontinued.

ABSTRACT: Adolescent drivers with attention deficit hyperactivity disorder (ADHD) are more likely to be involved in--and to die of--a driving accident than any other cause. The higher occurrence of driving mishaps is not surprising given that the core symptoms of ADHD are inattention, impulsivity, and hyperactivity. Safe driving habits can diminish the risk, however. The first step is to inform patients of the dangers of driving; the significance of adolescence, ADHD, and medication can be underscored in a written "agreement." Strategies to promote safer driving--especially optimally dosed long-acting stimulant medication taken 7 days a week--may be critical. A number of measures lead to safer driving by reducing potential distractions during driving (eg, setting the car radio before driving, no drinking or eating or cell phone use while driving, no teenage passengers in the car for the first 6 months of driving, and restricted night driving).

How old does a child need to be before we can count on the accuracy of his or her response?

One of the most common illnesses we treat in general pediatrics is asthma-often in children who have not yet entered their teen years. While we ask the parents what symptoms they have noticed in their child, we don’t always ask younger children directly. How reliable are their answers?

ABSTRACT: Because foreign-body aspiration can cause symptoms that mimic those of other respiratory conditions, a high index of suspicion is crucial in all children who have pneumonia, atelectasis, or wheezing with an atypical course--especially when these conditions are unresponsive to usual medical therapy. A history of choking can usually be elicited in a patient who has aspirated a foreign body: such a history should be sought when respiratory symptoms develop suddenly. However, the absence of a choking history does not rule out foreign-body aspiration. Moreover, patients may be asymptomatic initially. Normal radiographic findings do not exclude an aspirated foreign body. Bronchoscopy should be strongly considered when an aspirated foreign body is suspected, even if radiographic images show normal findings. Rigid bronchoscopy is the procedure of choice for removing aspirated foreign bodies in children. Prevention of foreign-body aspiration can be enhanced through anticipatory guidance of parents/caregivers and through continued product safety efforts.

Foreign-body aspiration is a relatively common occurrence in children. It may present as a life-threatening event that necessitates prompt removal of the aspirated material. However, the diagnosis may be delayed when the history is atypical, when parents fail to appreciate the significance of symptoms, or when clinical and radiologic findings are misleading or overlooked by the physician.

A 12-year-old girl presents with a 1-year history of itchy lesions on her right leg. The lesions are worse during the winter. She has a history of atopic dermatitis and asthma.

Sixteen-year-old with a recurrent, painful, pruritic rash on right cheek and right eyelid. Current outbreak started 2 days earlier. The rash always appears in the same fashion and in the same location; it typically lasts a few days and resolves spontaneously.

The patient is a healthy 5-year-old boy who typically awakens 90 minutes after falling asleep. His parents find him screaming, sweaty, and standing up wide-eyed in bed (Figure A). These episodes occur 3 or 4 times a week. He is otherwise a happy, well-adjusted child who attends kindergarten. He has an older sibling with whom he gets along well. There have been no changes in the family.

A 17-year-old Asian male with no significant medical history presented to the emergency department (ED) with acute shortness of breath and associated left-sided chest pain. Symptoms began while the patient was at rest: the pain was sharp and worsened with inspiration. He denied a history of fever, trauma, cough, or any other constitutional complaints.

Chest pain in children evokes anxiety in patients and their parents--and prompts frequent visits to the pediatrician's office, urgent care facility, or emergency department (ED). In a prospective study, Selbst and colleagues reported that chest pain accounted for 6 in 1000 visits to an urban pediatric ED.

For several months, a 12-year-old boy has been bothered by intermittent pruritus of the feet. He is very active in sports all year, and his feet tend to perspire heavily. He has a family history of seasonal allergies. He says that the rash worsened after he used an over-the-counter hydrocortisone cream.

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed bio-behavioral disorder of childhood. It occurs in 6% to 9% of children--about the same prevalence as childhood asthma. It is also one of the most controversial diagnoses in children; parents are often perplexed about whether ADHD is underdiagnosed or overdiagnosed, or undertreated or overtreated. A good deal of this confusion stems from the fact that there are no laboratory tests, imaging studies, or psychological testing profiles that can be used to make the diagnosis.

The prevalence and incidence of sinus infection, or sinusitis, is increasing and has been estimated to affect 31 million persons in the United States each year. It is one of the most common reasons why patients seek a physician's care. If left untreated, sinusitis can cause significant physical symptoms and can negatively affect quality of life by substantially impairing the daily functioning of sufferers. For children, this can mean learning difficulties at school and for adults, a loss of efficiency at work.

What evidence is there that acetaminophen can cause or exacerbate asthma?

The use of analgesics, specifically acetaminophen, has been proposed as one of the mechanisms for the rise in asthma prevalence in the past 30 to 40 years.

The patient, a 13-year-old girl, was concerned about the development of a very itchy, painful, papular rash on her hands and feet. She had been previously well and had no history of illness other than a minor upper respiratory tract infection 2 weeks earlier. The distribution of lesions and the severe pruritus initially suggested scabies, which was treated with 5% permethrin cream. The rash did not improve with applications of this medication, however, and the patient returned the following day for care. She had no oral lesions but complained of mildly painful, nonswollen joints.

Until very recently, when it came to chronic cough, children were to be treated like little adults. In its 1998 guidelines on cough, the American College of Chest Physicians (ACCP) stated that "the approach to managing chronic cough in children is similar to the approach in adults."

The patient is an 8-year-old girl with a history of asthma and developmental delay. She complained of hip pain, and her pediatrician referred her to a pediatric orthopedist for consultation. Hip x-ray films were ordered; they revealed 3 round beads in the child's appendix.

"Flu" Season: Here We Go Again . . .

ABSTRACT: Children are at greater risk than adults for many travel-related problems, such as barotitis and barotrauma associated with flying, cold and heat injury, drowning, and infection with geohelminths. Most of these problems can be avoided with appropriate measures. To prevent insect-borne diseases, advise parents to apply permethrin to their children's clothing before the trip and apply slow-release DEET (30% to 35% concentration) to their skin every 24 hours. Infection with ground-dwelling parasites can be avoided by wearing protective footwear. At high altitudes, infants and children may experience acute mountain sickness. Acetozolamide (5 mg/kg/d, divided bid or tid) is an effective prophylactic; however, it is contraindicated in patients with sulfa allergy. Some preventive measures that are effective in adults may not be appropriate for children; for example, several medications used to control motion sickness are ineffective and associated with significant side effects in children.

Consultations & Comments: Advice That Could Help Save a Life Thank you for the excellent review of asthma prevention, classification, treatment, and long-term management in your May 2005 issue ("Asthma Update: Pearls You May Have Missed," page 219). The summary by Drs Linda S. Nield, Lisa Markman, and Deepak M. Kamat should bring most of us up-to-date on the medications and ancillary tools helpful in managing this increasingly prevalent chronic illness.

A 14-year-old African American boy presented during the winter months with a painless, nonpruritic, periumbilical rash that had been present for approximately 1 month. Initially bluish, the rash had become dark brown.

ABSTRACT: Asthma is a very serious yet very controllable illness. In acute exacerbations, bronchospasm can be reversed with nebulized albuterol (2.5 to 5 mg); give 2 additional treatments at 20-minute intervals and then every hour for the first few hours until wheezing resolves. Subcutaneous terbutaline and epinephrine are alternatives. Systemic corticosteroids may be needed to manage the acute attack (eg, 2 mg/kg of oral prednisone or pred-nisolone). In addition, an anticholinergic agent (eg, inhaled ipratropium) may be used. IV magnesium (25 to 50 mg/kg) and heliox have shown promising results in acute asthma. Maintenance therapy is indicated when daily symptoms occur more than twice per week or when nighttime symptoms occur more than twice per month; such therapy may also be warranted for an infant with exacerbations that occur less than 6 weeks apart or more than 3 times per year, or when other risk factors are present. Inhaled corticosteroids are the cornerstone of maintenance therapy and are mandatory for all patients with persistent asthma. Alternative treatments for children younger than 5 years include cromolyn and an oral leukotriene modifier (montelukast). Patient and parent education helps ensure proper drug administration, monitoring, and compliance.