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Pediatrics
in Review
Vol 14 No 11
November
1993
EDITOR
Robert J. Haggerty
University
of Rochester
School of Medicine
and Dentistr,i
Rochester,
CONTENTS
Rochester,
423
Poisoning
Alan D.
in Children
Woolf
Consultation
with
Eye Prophylaxis
Ronald
L. Poland
424
433
Sports
William
Index
447
14642
ABSTRACTS
EDITOR
Steven P. Shelov, Bronx,
Adolescents
MANAGING
Jo L.argent,
the
Specialist:
in the
Newborn
C. Bracikowski,
Gregory
S. Liptak
Chronic
Liver
Mews
Consultation
Snoring
Vincent
Disease
and
Infant
with
J. Menna,
in Children
Frank
the
Sinatra
Specialist:
John
T. McBride
New
Teny
Concepts
in the Management
Nolan
and Frank
Oberklaid
NY
Village,
IL
CA
EDITORIAL
BOARD
Moris A. Mgulo,
Mineola,
NY
Russell W. Chesney, Memphis,
TN
Catherine
DeAngelis,
Baltimore,
MO
Peggy C. Ferry, Tucson, AZ
Richard B. Go$dbloom,
Halifax, NS
John L Green, Rochester,
NY
RObert L Johnson, Newark,
NJ
ftJan M. Lake, Glen Ann, MD
Frederick
H. Lovejoy, Jr, Boston,
MA
John T. McBride, Rochester,
NY
Vincent J. Manna, Doylestown,
PA
Lawrence
C. Pakula. Timonium,
MD
Ronald L Poland, Hershey, PA
James E. Rasmussen,
Ann Arbor, MI
James S. Seidel, Torrance,
CA
Richard H. Sills, Newark,
NJ
Laurie J. Smith, Washington,
DC
William B. Strong, Augusta,
GA
Jon Tuigelstad,
Greenville,
NC
Vernon T. Tolo, Los Angeles,
CA
Robert J. Touloukian, New Haven, CT
Terry Yamauchi,
Little Rock, AR
Moritz M. Ziegler, Cincinnati,
OH
EDITORIAL
ASSISTANT
Sydney Sutherland
of Encopresis
ABSTRACT
431
Diaphragmatic
Hernia
444
Passive
Exposure
Smoke
EDITOR
Elk Grove
EDITORIAL
CONSULTANT
Victor C. Vaughan,
III, Stanford,
of Suspicion
Catherine
445
and
Medicine
L. Risser
Andrea
436
NY
ASSOCIATE
EDITOR
Lawrence
F. Nazarian
Panorama
Pediatric
Group
Rochester,
NY
ARTICLES
411
NY
Editorial Office:
Department
of Pediatrics
University
of Rochester
School
of Medicine
and Denhstr
601 Elrnwood
Aye, Box 777
in Children
COVER
“Sara
Handing
a Toy to the Baby”
was painted
by Mary
Cassatt
(1845 1925).
Cassatt,
an American
artist,
was the daughter
of a wealthy
Philadelphia
businessman.
She went to Paris to study and never
returned.
Most of her paintings
are of mothers
and children,
although
she herself
never
married.
This lovely
painting
shows
an older sibling
handing
a toy to
her younger
brother.
We all know that sibling
relations
are never
this
serene
at all times,
but we can always
encourage
the sharing
and love so
beautifully
shown
here.
(This painting
is reproduced
with the permission
of
the Hill.Stead
Museum,
Farmington,
CT).
ANSWER
KEY
1. E; 2. B; 3. E; 4. B; 5. C; 6. E; 7. B; 8. D; 9. A 10. E; 11. B; 12. A
13. B; 14. C; 15. D; 16. E; 17. A; 18. D; 19. D; 20. B; 21. C; 22. C
PUBUSHER
American
Academy
of Pediatrics
Errol R. Alden, Director,
Department
of Education
Jean Dow, Director
Division of PREP/PEDIATRICS
Deborah Kuhlman, Copy Editor
PEDIATRICS
IN REVIEW
(ISSN 0191-9601)
is
owned and controlled
by the American
Academy
of Pediatrics.
It is published
monthly by the
American
Academy of Pediatrics,
141 Northwest
Point Blvd, P0 Box 927, Elk Grove Village, IL
60009-0927.
Statements and opinions expressed in Pediatrics
in Review
are those of the authors
and not
necessarily
those of the American Academy
of
Pediatrics
or its Committees.
Recommendations
included
in this publication
do not indicate
an
exclusive course of treatment or serve as a standard
of medical care.
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POSTMASTER:
Send address
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PEDIATRICS
IN REVIEW, American Academy
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in Review is
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r-
EDUCATION
in the USA
-
POISONING
Poisons
Cadranel S, DiLorenzo C, Rodesch
Caustic ingestionand esophageal
Pediatr
Gastroenterol
Nutrition.
P. et al.
function. J
1990;
10:164-168
Gaudreault P, Parent M, McGuigan MA, et al.
Predictabilityof esophageal injuryfrom
signs and symptoms: a study of caustic
ingestionin 378 children. Pediatrics.
1983;71 :767-770
Foreign
Tricyclic
Antidepressants
Boehnert MT. Lovejoy FH. Value of the ORS
duration versus the serum drug level in pre-
Bodies
AAP, Committee
on Accident & Poison Prevention. First aid for the choking child1988. Pediatrics. 1988;81:740-742
Blazer S, Naveh Y, Friedman A. Foreign body
in the airway-a
review of 200 cases. Am J
Dis Child.
1980;134:68-71
CDC. Toy safety-United
States, 1984.
MMWR.
1985;34:755-756, 761-762
Mu L, He P. Sun D. The causes and complications of late diagnosis
of foreign body aspiration in children. Arch Otolatyngol
Head
Neck Surg. 1991; 117:876-878
Hydrocarbon
Anas N, Namasonthi
V, Ginsburg
CM. Critena for hospitalizing
children who have ingested products containing
hydrocarbons.
JAMA.
1981;246:840-843
Klein BL, Simon JE. Hydrocarbon
poisonings.
Pediatr
Clin North Am. 1986;33:41
1-419
Iron
Henretig FM, Temple AR. Acute iron poisoning in children.
Emerg
Clin North Am.
1984;2: 121-132
LaCouture
PG. Wason S, Temple AR, et al.
Emergency
assessment
of severity in iron
overdose by clinical and laboratory
methods.
J Pediatr. 1981 ;99:89-91
Proudfoot
AT, Simpson D, Dyson EH. Management of acute iron poisoning.
Med TaxicoL 1986;1:83-100
Salicylates
Done AK. Salicylate
intoxication:
significance
of measurements
of salicylate
in blood in
cases of acute ingestion.
Pediatrics.
1960;26:800-807
Gaudreault
P, Temple AR, Lovejoy FH. The
relative severity of acute versus chronic salicylate poisoning
in children:
a clinical
comparison.
Pediatrics.
1982;70:566-569
Snodgrass
WR. Salicylate
toxicity. Pediatr
Clin North Am. 1986;33:381-391
PIR QUIZ
1. You receive a callfrom a parent
who suspects her child has taken
some medicine inappropriately.
Which of the following
situations is
least worrisome?
A. A previously healthy 2-year-old
boy has taken 12 150-mg ferrous
fumerate tablets.
B. A 2-year-old
girl has taken six
10-mg imipramine tablets.
C. A 3-year-old girl who has symptomatic reactive airway disease
has taken three 10-mg propranolol tablets.
D. A 3-year-old boy on chronic salicylate therapy for systemic onset juvenile
rheumatoid
arthritis
has ingested 1 tsp of oil of wintergreen.
E. A 10-year-old
boy has taken six
150-mg ferrous fumerate tablets.
2. A 3-year-old
child appears inebriated. Her blood alcohol level is
zero. Which of the following substances is most likely to be responsible for her symptoms?
A. Acetaminophen.
B. Antifreeze.
C. Diet pill.
D. Hydrogen peroxide.
E. Oil of wintergreen.
3. A 15-year-old
girl is brought to the
emergency
department
in a nearly
comatose
state from a party where
she had been drinking vodka punch
all night. Of the possible immediate
interventions
listed below,
which
will contribute
most to safe and effective management?
A. Administer 2 tbsp ipecac orally.
B. Administer a loading dose of Nacetylcysteine.
C. Give sodium bicarbonate
intravenously
to produce ion trapping
in the renal tubules.
D. Instill a magnesium
citrate cathartic in the stomach.
E. Obtain blood and urine for toxic
screening and calculateosmolar
gap.
4. In a few types of poisoning,
quantitative blood levels are instrumental
in selecting appropriate
management. In each example below, the
blood level listed has been obtained
4 hours after the ingestion occurred.
In which case is treatment unnecessaiy?
A. Ethylene glycol 26 mg/dL.
B. Iron 275 g/dL.
C. N-acetyl-para-aminophenol 225
g/mL.
D. Salicylate 76 mg/dL.
E. Theophylline
33 pg/mL.
Match the following
poisons (5-9)
their specific antidotes (A-E).
5. Acctaminophen
6. Digitalis
7. Ethylene glycol
8. Iron
9. Isoniazid
with
A Ethanol
B Pyridoxine
Theophylline
C Specific Fab antibody
D Deferoxamine
E N-acetylcysteine
Gaudreault
P. Guay J. Theophylline
poisoning-pharmacological
considerations
and
clinical management.
Med ToxicoL
1986;1:169-191
422
dicting seizures and ventricular
arrhythmias
after an acute overdose of tricyclic antidepressants.
N Engi J Med.
1985;313:474-479
Frommer
DA, Kulig KW, Marx JA, Rumack
B. Tricyclicantidepressantoverdose-a review. JAMA.
1987;257:521-526
Gallant DM. Antidepressant
overdose:
symptoms and treatment.
Psychopathology.
1987;20(suppl
1):75-81
Olson KR, Benowitz
NL, Woo OF, Pond SM.
Theophylline
overdose:
acute single ingestion versus chronic repeated overmedication.
Am J Emerg
Med.
1985;3:386-394
Pediatrics
in Review
VoL
14
No.
11
November
1993
SPORTS
Sports
the muscle further during overly vigorous rehabilitation.
Myositis
ossificans
is the deposition of bone in the area of injury.
The clinician
can palpate a firm mass
3 to 4 weeks after injury, and radiography demonstrates
calcification.
A
radionuclide
bone scan may show
this process sooner than will a radiograph.
Some experts believe that aspirin
and nonsteroidal
antiinflammatory
drugs are inappropriate
therapy for
contusions
because of their risk of increasing
bleeding.
The research
in
this
area
whether
avoided.
is not adequate
these
Adolescent
should
be
I benefited
READING
Berning JR, Steen SN. Sports
90s:
The Health
Professional’s
Nutrition
for
Handbook.
State
of the Art
Care
and Management.
Philadelphia,
PA: WB Saunders Co; 1990
Risser WL. Exercise for children.
Pediatr
Rev.
1988;1O:131-139
Risser WL. Musculoskeletal
injuries caused by
weight training. Clin Pediatr.
1990;29:305310
Roy 5, Irvin R. Sports Medicine.
Englewood
Cliffs, NJ: Prentice-Hall,
mc; 1983
Diagnosis
PIR QUIZ
from direct help from Dr. Oded BarOr, Dr. Paul Dyment,
Dr. Jack B.
Jeffers,
Mr. Richard Malacrea,
ACAT, and Mr. Brian McGeeven,
LAT, and from articles written by
Drs. Bar-Or,
Dyment,
Barry Goldberg, Greg Landry,
and Michael
Nelson.
SUGGESTED
Medicine:
1991;2:1-250
Dyment PG, ed. Sports Medicine:
Health
for Young Athletes,
2nd ed. Elk Grove
Village, IL: American
Academy
of
Pediatrics;
1991
Garrick JG, Webb DR. Sports Injuries:
Reviews.
to determine
medications
Acknowledgments:
Gaithersburg, MD: Aspen Publishers; 1991
Dyment PG. ed. Sports and the adolescent.
MEDICINE
Medicine
the
The following conditions should
exclude an athlete from participation in collision/contact
and limited
contact/impact sports except:
A. A palpable spleen tip.
B. Poorly controlledseizures.
C. Two concussions
with loss of
consciousness.
D. Uncorrectable
poor vision in
one eye without eye protection.
E. Upper respiratoly infection with
fever.
10. Injuries can be reduced by all of
the following except:
A. Face protectors
in hockey.
B. Matching
competitors
by
weight and pubertal development.
C. Use of breakaway bases in
softball.
D. Use of ear protectors
in wrestling.
E. Use of knee braces in uninjured
athletes.
12.
11. Of the following,
the most cornmon reason for trauma suffered by
juvenile athletes is:
A. Acute dehydration to make a
weight categoty.
B. Incomplete healing of a previous injury.
C. Use of anabolic steroids.
D. Use of improper protective
gear.
13. Guidelines for the treatment of hematomas and contusions
are contamed in the acronym RICE. These
letters stand for all of the following
except:
A.
B.
C.
D.
Rest.
Immobilization.
Compression.
Elevation.
ABSTRACT
Diaphragmatic
Hernia
Congenital
Diaphragmatic
Hernia:
Association
Between Pulmonary
Vascular
Resistance
and Plasma Thromboxane
Concentrations.
Ford WDA, James MJ,
Walsh JA. Arch Dis Child. 1984;59:143146
Ventilatory
Predictors
of Pulmonary
Hypoplasia
in Congenital
Diaphragmatic
Hernia,
Confirmed
by Morphologic
Assessment.
Bohn D, Tamura M, Perrin D,
et al.J Pediatr. 1987;1 11:423-431
Effect of Surgical Repair on Respiratory
Mechanics
in Congenital
Diaphragmatic
Hernia. Sakai H, Tamura M, Hosokawa
Y,
et al. J Pediatr.
1987;1 11:432-438
Diaphragmatic Hernia in the Fetus:
Prenatal
Diagnosis
and Outcome
in 94
Cases. Adzick NS, Harrison MR. Glick PK,
et al. J Pediatr
Surg.
1985 ;20:357-361
Fetal Diaphragmatic
Hernia: Ultrasound
Diagnosis
and Clinical Outcome
in 38
Cases. Adzick NA, Vacanti JP, Lillehei
CW, et al.J Pediatr
Surg.
1989;24:654657
Congenital
diaphnagmatic
hernia almost always is due to a posterolateral
defect of the diaphragm,
which results from the persistence
of the pleuPediatrics
in Review
VoL
14
No.
11
roperitoneal
canal on fonamen of
Bochdalek.
The hernia usually is on
the left side. Displacement
of abdominal organs,
including
bowel, liven,
and/on spleen, into the chest results
in mediastinal
shift toward the opposite side and in homolatenal
or bilatenal lung hypoplasia.
In patients who have congenital
diaphragmatic
hernia, oxygenation
in
the neonatal
period may be limited
by severe lung hypoplasia
as well as
by pulmonary
hypertension,
which
may result from decreased
pulmonary
vascular
bed, pulmonary
arteniolar
muscular
hypertrophy,
and increased
thromboxane
production.
Many of
these patients present immediately
after birth having severe respiratory
distress (dyspnea
and cyanosis)
associated with decreased
breath sounds
on one on both axillae, increased
resistance to ventilation,
and shift of
heart sounds and precordial
pulsa-
November
1993
tions toward the right. Although
those signs also are compatible
with
the diagnosis
of left pneumothonax,
their presence
immediately
after birth
is strongly
suggestive
of diaphragmatic hernia. In addition,
many, but
not all, patients
have a scaphoid
abdomen, which results from displacement of abdominal
viscera into the
chest. The infant should be examined
carefully
for possible
associated
cardiovascular,
skeletal,
or central ncrvous anomalies
on multiple
congenital anomalies.
Delivery
room resuscitation
includes the administration
of 100%
oxygen,
tracheal
intubation,
and
manual ventilation.
Because
of lung
hypoplasia,
small tidal volumes
should be used to limit the risk of
pneumothorax;
a high ventilatory
rate
often is required
to obtain a normal
pCO2. To limit distension
of the gastrointestinal
tract, bag and mask yen431
GASTROENTEROLOGY
Chronic
Uver Disease
PIR QUIZ
14. Exposure of a previously well child
to which of the following viruses is
most likely to result in development of chronic hepatitis?
A. Epstein-Barr.
B. Hepatitis A.
C. Hepatitis B.
D. Hepatitis D.
E. Hepatitis E.
15. Of the following medications,
which has shown the most promise
in the management
of hepatitis B?
A. Adenine arabinoside.
B. Corticosteroids.
C. Cyclosponine.
D. Interferon-alpha.
E. Thymosine.
16. A 7-year-old boy has had recent
episodes of jaundice, after which
he has been noted to be somewhat
clumsy. Physical examination
reveals moderate hepatomegaly
and a
mild intention tremor. No other al,.
normalities
are found. Of the following diagnoses,
it may be most
urgent to exclude:
A. Alpha-l-antitrypsin
deficiency.
B. Epstein-Barr viral hepatitis.
C. Glycogen
storage disease.
D. Portal hypertension.
E. Wilson disease.
17. Among the following,
the disorder
for which children most commonly
undergo liver transplantation
is:
A. Alpha-1-antitiypsin
deficiency.
B. Cystic fibrosis.
C. Hemochromatosis.
D. Primary sclerosing
cholangitis.
E. Wilson disease.
18. Among the following,
the prima,y
goal of current therapy for hepatic
encephalopathy
is:
A. Correction
of nutritional
deficiencies.
B. Improvement
of cerebral blood
flow.
C. Normalization
of neurotransmitter activities.
D. Reduction
in ammonia produc-
tion.
E. Replacement of coagulation
factors.
ABSTRACT
Passive
Smoke
Exposure
Don’t Let Our Youth Go Down Tobacco
Road. Bradford BJ. Contemp
Pediatr.
1992;(August):96-l
13
Childhood
Asthma
and the Indoor
Environment.
Dekker C, Dales R, Bartlett
s, Brunekreef B, Zwanenburg
H. Chest.
1991 ; 100:922-926
Maternal
Smoking
and Childhood
Asthma.
Weitzman
M, Gortmaker
S. Walker DK,
Sobol A. Pediatrics.
1990;85:505-511
Relationship
of Parental Smoking to
Wheezing
and Non-wheezing
Lower
Respiratory
Tract Illnesses in Infancy.
Wright AL, Holberg C, Martinez FD,
Taussig LM.JPediatr.
1991;118:207-214
Cigarette
smoking
is the single most
preventable
cause of disease and
death in the United States today.
Children
who live in homes with
smokers
are exposed
to sidestream
and second-hand
cigarette
smoke.
This involuntary,
or “passive,”
smoking
increases
children’s
risk of
having serious respiratory
illnesses.
Almost 50% of all children
are
exposed
to cigarette
smoke by one or
more adults in their home.
Children
exposed
to passive smoke
have more lower respiratory
tract
infections,
including
pneumonias,
bronchitis,
and serious respiratory
syncytial
virus infections.
The
frequency
of respiratory
infections
increases
with the amount of parental
smoking.
The respiratory
problems
resulting
from these exposures
cause
more “disability
days” for these
children and more “out of work”
days for their parents.
Children
exposed to smoke also have more
frequent
and longer hospitalizations
for these problems
as well as higher
overall mortality
rates.
Children whose parents smoke also
manifest
long-term
effects,
including
decreased
lung function
and
decreased
lung growth,
compared
with children
of nonsmoking
parents.
They have more chronic respiratory
symptoms,
especially
persistent
wheezing,
and are more likely to
develop asthma.
Smoke exposure
also results in more severe symptoms
in children
who
have
adults
to develop
symptoms,
Pediatrics
respiratory
asthma,
infections
“indoor
and lung
from exposure
air pollution,”
generated
to other
such as that
by wood-burning
stoves,
gas cooking
fuels, and aerosol
spray
products.
These exposures
likely help
disrupt
underlying
lung host defense
mechanisms.
Pediatricians
can
influence
thus,
reduce
behaviors
and,
children’s
exposure
parents’
to environmental
tobacco smoke and to indoor air
pollution.
Remembering
to ask about
smoke exposure,
advising
and
assisting
arranging
cessation
element
parents
in quitting,
and
follow-up
for smoking
each is an important
of brief,
effective
preventive
counseling
interventions.
Pcdia-
tricians
also should
advocate
for and
participate
in antismoking
educational
programs
promote
awareness
associated
in children’s
schools
public and legislative
of the health
with smoking.
and
problems
Jonathan
D. Klein,
MD, MPH
Assistant
Professor
of Pediatrics
Division
ofAdolescent
Medicine
University
of Rochester
School
Medicine
Rochester,
NY
of
Comment:
We’ve continued
to see
an alarming
increase in the incidence
of smoking
in our teenage children
that
will
significant
make
the potential
number
for a
of adult
smokers
a
reality
over the next decade.
Targeted educational
activities
with the
assistance
of pediatricians
at the
school-age
population,
especially
junior high school, would be
significant,
with the potential
payback
of affecting
that age group.
it appears clear through studies
conducted
by the Consumer
Product
Safety Commission
and others that
cigarette
young
smoking.
asthma.
Exposure
to environmental
or passive
tobacco smoke is associated
with
more chronic ear infections,
and
children
exposed
to a parent’s
smoke
also are at greater risk of becoming
smokers
themselves.
infants and small children
also are
more likely than older children or
444
in Children
advertising
viewers
Active
of pediatricians
important
does
indeed
a positive
efforts
view
give
of
on the part
is extremely
in letting
such
advertisers
know the deleterious
effect such
potential
messages
might have on our
youth and future generations.
Steven
P. Shelov,
Abstracts
Editor
in Review
VoL
14
MD
No.
11
Noventher
1993