Consultant for Pediatricians Vol 5 No 8

The parents of a 3-year-old girl sought evaluation of their daughter's hair loss. During the past several months, a large patch of alopecia with scaling had developed. The differential diagnosis included seborrhea, trichotillomania, and tinea capitis. Joe R. Monroe, PA-C, MPAS, of Tulsa, Okla, writes that in seborrhea, scaling typically occurs throughout the scalp without the patches of alopecia seen in this patient. Broken-off hairs--a key to trichotillomania--were absent here. A potassium hydroxide preparation of scrapings that contained hairs from the affected area were positive for the "endothrix" phenomenon--the finding of fungal elements inside the hair shaft. Palpable, tender suboccipital lymph nodes were also detected. Both of these findings are common in tinea capitis and essentially confirm the diagnosis.

Right lower leg pain prompted a 15-year-old boy to seek medical attention. An hour earlier, he had fallen on the leg during a football game and on standing had heard a "pop." No gross abnormality was noted. Jack-Ky Wang, MD, and Laurie Meng, PA-C, of Palos Heights, Ill, report that radiographs revealed a transversing pathologic fracture through an expansile lytic lesion of the right fibula.

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.

Musculoskeletal infections in children encompass a broad spectrum of entities that vary greatly in severity and complexity. Their presentation ranges from obvious and acute to insidious and chronic.

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.

A 6-month-old infant was brought for evaluation of an "atypical mole" on the chest that her parents and referring physician feared might be skin cancer. The parents reported that the lesion had been present since shortly after birth and had become red and inflamed after minor trauma on a few occasions and once had blistered.

Attention deficit hyperactivity disorder (ADHD) is very common. In the United States, between 6% and 10% of children and adolescents are affected, as are 4% of adults.1 Children in other countries also have ADHD, although rates of comorbid disorders may vary from those found in the United States.2

The adoptive parents of an 11-month-old infant noticed that their son did not use his right arm as often as the left. Concern for brachial plexus injury was raised. Antenatal, natal, family, and early developmental history were unknown.

There are many exciting new studies of the biologic basis of ADHD that use neuroimaging and genetic testing. However, none of these methods can reliably diagnose this complex disorder. Someday, these technologies will be used to help subtype ADHD and improve treatment matching.

A 27-month-old boy is brought by his mother to the emergency department (ED) with a 1-day history of sluggish behavior and unsteady gait. The child had been sleepy but was arousable.

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.

This past February, I wrote an editorial for this journal called "Skeptical Sentiments."1 In that essay, I mentioned the satisfaction I had derived from helping children and families during my 30-year career as a pediatrician. I also listed a series of things and situations I have learned to distrust. Chief among them were:

An 8-year-old boy was brought to the emergency department with fever, bloody and mucous diarrhea, and abdominal pain. Specimens for stool culture were sent to the laboratory, and therapy with trimethoprim/sulfamethoxazole (TMP/SMX) was initiated.

Two excellent review atricles on attention deficit hypertention disorder (ADHD) follow. The first, by Michael Reiff MD, of the university of Minesota, presents an overview of the assessment and diagnosis of ADHD with clear, straightforward recommendations for the primary care practictioner illustrated with clinical vignettes. The format lends itself to a quick read, but the details are included if you want to drill down.

A 12-year-old boy from Pakistan presented with weakness, night sweats, anorexia, and chronic cough of 2 months' duration. He had undergone spinal surgery about 5 months before immigrating to the United States when acute paralysis, kyphosis, and a prominent midline hump (gibbus deformity) developed in his thoracic spine. The child appeared pale and weak but in no acute respiratory distress. His weight was 20.5 kg (45 lb). He had difficulty in walking without assistance. Muscle wasting was noted in the arms and legs, and he had a healing lesion on the left elbow that drained pus. Other physical examination findings were unremarkable except for a fever (temperature of 37.2°C [99°F]) and the gibbus deformity.

This 18-year-old girl had been taking divalproex for seizure disorder for 2 years. Because she had gained weight while taking this medication, the patient asked for another drug. Her neurologist prescribed lamotrigine. Ten days after starting the new agent, a generalized, painful, pruritic, ery- thematous dermatitis; fever; and sore throat developed.

The patient was a 6-year-old boy who had Menkes syndrome and bladder diverticula. He was receiving care at home with sterile intermittent catheterization.

A 16-month-old toddler was brought to the emergency department after he and the sibling who was carrying him fell down a flight of stairs. The child had not been able to bear weight on his left ankle since the fall and resisted his mother's efforts to put on his shoe. Prior medical records showed no history of broken bones or evidence of past abuse or questionable injuries.

Six-year-old East Indian boy delivered by normal spontaneous vaginal delivery to a para 3, gravida 2, 42-year-old mother following uncomplicated, full-term pregnancy. Apgar scores: 9 and 9, at 1 and 5 minutes, respectively. Birth weight, 2.5 kg. Infant hypotonic at birth with numerous dysmorphic features. Delayed developmental milestones; IQ measured at 80.

Infants and toddlers will put just about anything into their mouths. Each year in this country, between 100,000 and 200,000 incidents of foreign-body ingestions are reported to poison control centers.1,2 The large majority of ingestions are accidental. (In adolescents, ingestions are usually intentional.)

For 2 days, a 4-year-old girl had complained of discomfort and a yellow discharge from the left eye. The left conjunctiva was hyperemic, but there was no preauricular lymphadenopathy.