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Expanding the differential diagnosis

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Choose article section... Dark skin needs sun protection, too Another clue to nursemaid's elbow When there's an aversion to white foods Vitamin D, breastfeeding

"Update on intussusception" (March) includes an excellent review of the causes of emesis in the neonate, such as intestinal obstruction, reflux/ regurgitation, formula intolerance, trauma/abuse, infections, CNS mass, and renal and adrenal pathologies. We suggest also considering excessive breast milk intake secondary to maternal overproduction as a possible cause for recurrent, nonbilious emesis in a breastfeeding neonate appropriately worked up to rule out other important causes of recurrent emesis.

One of our patients, a term male who weighed 3,292 g, had nonbilious vomiting within minutes each time he breastfed during the first 48 hours of life. The infant had a normal physical exam and stable vital signs, an unremarkable CBC, metabolic panel, kidney, ureter, and bladder, and a negative blood culture. Because the mother felt engorged within 12 to 24 hours after delivery, she was advised to use a breast pump, and about 6 oz of milk were expressed from each breast. Since the stomach of a term newborn can hold about 4 oz, we attributed the emesis to ingestion of more than this amount. When breastfeeding was discontinued, the patient's weight was at a nadir of 3,031 g. When routine on-demand feedings with pumped breast milk were begun, the emesis subsided, and the baby's weight had increased to 3,121 g by the time he was discharged on the fourth day of life. When working up recurrent nonbilious emesis in a breastfeeding neonate, we suggest having the mother pump her breast to quantify the amount of breast milk being produced, so as to avoid overfeeding.

Andrew A. Rusnak, MDAlbert F. DiNicola, MDCamp Pendleton, CA

The author replies: Thanks to Drs. Rusnak and DiNicola for pointing out an additional consideration in the differential diagnosis of vomiting. They correctly point out that an overactive letdown reflex may produce vomiting, as well as choking and colicky behavior. Not having faced this situation clinically, I would hazard a guess that the absence of blood in the stool would be an early way to steer away from the diagnosis of intussusception. In managing the over-nursed infant, offering one breast while expressing milk from the other might be an alternative to pumping from both breasts.

Julian Orenstein, MDFalls Church, VA

Dark skin needs sun protection, too

Table 1 of "Sun protection three ways" in "Skin care in infancy and early childhood" (May supplement) conveys the idea that black skin needs no sun protection because it neither tans nor burns. This is a misconception and not helpful to those caring for brown- or black-skinned children. The take-home message should be that all skin is capable of burning—severely, I might add—and needs sun protection care. Let's educate all!

Caren L. Thompson, MDWilmington, DE

The author replies: I believe Dr. Thompson is absolutely correct. In the text of my article, I state that "sunscreen should be used on all children and infants..." without any exception for ethnicity or skin color. The table that Dr. Thompson takes issue with, while attached to my article, was from another Contemporary Pediatrics article ("Sun, kids, moles, and melanoma," June 1999).

While skin types V and VI (brown and black, respectively) are less likely than other skin types to get severe burns, they certainly can suffer sunburns as well, and do deserve sun protection. It should be further noted that swarthy, brown, and black skin respond to trauma of all types with longstanding and difficult-to-treat hyperpigmentation. One should not underestimate, then, the possibility of swarthy, brown, or black skin tanning or burning.

Lawrence A. Schachner, MDMiami, FL

Another clue to nursemaid's elbow

"Nursemaid's elbow: Pulling out the diagnosis" (June) was a nice review of a common pediatric injury. I'd like to offer my opinion—based on observation only—about the pain children with this condition feel. The authors mention that palpation produces point tenderness over the radial head laterally, that restriction of shoulder motion to protect the elbow may be seen, and that the child actively guards against supination of the forearm, all of which are commonly seen. I have found, however, that asking children who are old enough to respond appropriately (or asking the parents) where the pain is usually elicits finger pointing at the distal forearm, most often on the radial side. Why? Because the child knows that if the hand, wrist, and distal forearm are supinated, it will be painful, and since the pain was caused by a movement of the distal forearm, in the child's mind that's the place that really hurts. Reviewing the history typically suggests that there shouldn't be an injury of the distal forearm, and that leads back to the likelihood of radial head subluxation. Along with the appropriate history and other physical findings already mentioned, "pain" at the distal forearm is a very reliable sign of radial head subluxation.

Richard H. Strauss, MDLa Crosse, WI

When there's an aversion to white foods

Dr. Kemper's comments on the patient who suddenly restricted his diet to white foods (Behavior: Ask the experts, June) were interesting and helpful. I wonder, however, if some additional possibilities might need to be considered. I am a general pediatrician with no particular extra training in behavioral pediatrics. I had a patient with obsessive-compulsive disorder (OCD) who presented with similar food preferences; the fixation on the particular color of the food seemed somewhat suspicious to me (vs. the ever-popular aversion to anything green or remotely healthy). Also, I believe some patients with eating disorders can have this sort of odd dietary habit, believing that foods of a certain type or color will not cause weight gain. Perhaps some further investigation into this patient's psychiatric health and family dynamics would be helpful.

Pippa C. Abston, MD, PhDMadison, AL

The author replies: Dr. Abston raises a valid issue. I received an e-mail from another pediatrician who also raised the question of whether this child might be exhibiting early signs of OCD. It's a good thing to keep in mind, and I think that if the parents raise other, similar concerns, I would pursue it. But in the meantime, when I hear hoofbeats, I'll probably still think of horses first.

Kathi J. Kemper, MD, MPHBoston, MA

Vitamin D, breastfeeding

In "Fielding questions about breastfeeding" (April 1999), the authors state that "most healthy infants do not need any vitamin supplementation." This statement contradicts the recommendations of the 1996-1997 Committee on Nutrition's report found in the American Academy of Pediatric's Pediatric Nutrition Handbook (ed 4, p 275): Vitamin D supplementation at 400 IU/day is recommended for breastfed infants.

We should be pleased that more mothers are choosing to breastfeed, but as physicians continue to encourage breastfeeding, it is likely that the incidence of vitamin D-deficiency rickets in exclusively breastfed infants will increase. In view of this potential increase and the recommendations of the AAP, it seems reasonable to start patients who are exclusively breastfed on vitamin D supplementation.

Paul Allen, MD

The author replies: Dr. Allen's comments are appreciated. The 1997 AAP statement by the Work Group on Breastfeeding, issued after the Committee on Nutrition's report, also offers guidelines: "Vitamin D and iron may need to be given before 6 months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin D-deficient or infants not exposed to adequate sunlight; iron for those who have low iron stores or anemia [American Academy of Pediatrics Work Group on Breastfeeding: Breastfeeding and the Use of Human Milk. Pediatrics 1997;100:1035].) Instead of treating all infants with Vitamin D to protect a few from rickets, I prefer supplementing only those babies who are at high risk (dark-skinned or veiled mothers, northern climates, winter months) and discussing ways to increase sunlight exposure with the parents of low-risk infants, especially during winter months.

Barbara L. Philipp, MD, IBCLCBoston, MA


Julia McMillan. Letters. Contemporary Pediatrics 2000;9:16.

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