Dr. Olson Huff and Dr. Susan Mims fill out a prescription for children's health at the Capitol.
Dr. Huff leads a hands-on field trip.
AAP NCE 2009
Monday, October 19, 2009
Dermatology Potpourri
Albert Yan, MD
- Warts
- Often start with thrombosed capillaries
- Natural skin markings go away
- May just observe
- Takes 6 months to 6 years to go away, 2/3 within two years without treatment
- No single wart treatment is so effective as to dominate
- Hot water soaks at 110 degrees for 5 minutes every night is actually very effective (86%)
- Salicylic acid therapy - surround wart with petrolatum, apply acid, cover with occlusive waterproof tape (duct tape)
- Follow up with pumice stone, nail file as material builds up
- Cure rate 75%
- Dimethyl ether/Propane -70 degrees Celsius
- Liquid nitrogen - 196 degrees Celsius, a bit more effective
- Repeat freezing q 2 to 3 weeks until resolved
- Emphasize patience
- Cure rate better with more frequent treatment, 70-80% at q 2 to 3 weeks
- Laser therapy
- Painful
- High energy levels generate lots of heat
- No more effective than cryotherapy
- Cantharadin (Beetlejuice)
- Apply small amount in office
- Use higher of the two available compounds
- May cover warts with tape afterward
- Must wash off after two to four hours.
- May blister, fall off within 1 to 2 weeks
- Risk of ring warts when you only kill the center of the wart
- Repeat q month until warts resolved.
- Cimetidine
- 25 to 40 mg/kg/day divided TID
- Resolution in children may be as high as 80%
- Resolution not as good in adults
- Dose toward the high end of the range, maximum 800 mg per dose
- Especially useful in children with many warts, too many to treat individually
- Duct tape
- Leave on as long as possible
- Other topical therapies
- Urea 20% and 40%
- Topical retinoid
- Imiquimod cream
- Sinecatechin cream
- Molluscum Contagiosum
- Can identify using side light from otoscope to see umbilication, core
- When eczema exists, treat the eczema first to avoid spread to inflamed skin
- Should resolve within 6 to 15 months untreated
- Dimpling may occur whether or not lesions are treated
- Scars are rarely permanent
- Can treat with topical retinoids like treinoin, adapalene, tazarotene
- May use toothpaste, silver nitrate, KOH, but hard to control irritation
- Topical imiquimod
- If using cantharidin then use lower 0.7% concentration for molluscum
- Avoid face and genital areas if using cantharidin
- Treat 12 to 24 lesions at a time
- 90% clear
- Aloe Vera gel may work against molluscum
- Tinea
- Don’t use LOTRISONE or MYCOLOG! Weak antifungal, strong steroid
- If you’re unsure of diagnosis confirm with KOH or with culture
- If inflammatory and itching, use a low-potency topical corticosteroid
- Remember scaling scalp has many causes, not just tinea capitis
- Griseofulvin 20 to 25 mg/kg/day
- May cause id reactions, papular rash around the ears
- Treat through id reactions, not through urticaria
- If serious penicillin allergy history then consider another drug
- Terbinafine for two to four weeks, especially good for trichophyton
- Get baseline LFT’s, especially if following an unsuccessful course of griseofulvin
- Fluconazole
- Mainly used under six months of age
- But at that age topical therapy often works
- 6 mg/kg/day x 3 to 6 weeks
- Resistance
- Increase dose or duration of therapy
- Consider reinfection from fomites
- Treat other family members with antifungal shampoo
- Head Lice
- If a nit is more than 1 cm from the scalp it’s already hatched
- OTC Treatments often fail up to 50% of the time
- May try permethrin rinse plus cotrimoxazole or Septra/Bactrim
- Malathion kills well even after 20 minutes, so may use just one hour
- Suffocants
- Petrolatum, mayonnaise, olive oil: petrolatum works best but hard to wash out
- May apply Cetaphil cleanser to the scalp once weekly three times
- Apply and blow-dry, leave on overnight
- Lice asphyxiation
- Monohydric aralkyl alcohol (Ulesfia) 75% cure rate
- Ivermectin PO, not safe in children under 15 kilos, rarely needed
- Robi Comb - zaps lice with electricity. Must be used on dry hair. Not clear if it works well.
- Scabies
- Permethrin 5% cream works well applied x 8 hours q week
- Treat all members of the household
- Percipitated sulfur can be compounded, useful for pregnant patients, infants
- 8% compound in petrolatum
- Ivermectin works for resistant cases, not safe in children under 15 kilos or in pregnant women
- Remember itching persists after scabies are killed
- Diaper Dermatitis
- Candida will colonize any rash present >72 hours
- Look for rash that follows blue or green dye from diaper
- Psoriasis can present early in the diaper area
- Pseudoverrucous Perianal Papules
- Result from chronic wetness
- Inflammatory lesions may be associated with Crohn’s disease
- Kawasaki’s presents in the diaper area
- Strep intertrigo in diaper area, other creases, SMELLS BAD
- Zinc deficiency with diaper rash, facial rash as well
- Histiocytosis X may present in diaper area, look for oral lesions as well
Psychopharmacology in Preschool Children, Christopher Kratochvil, MD
- Very little data but lots of use of drugs in these children
- Psychotropic medication use up from 2/1000 children to 20/1000 children from 1991 to 2001
- Only one randomized controlled trial in preschool children
- Diagnosis and Treatment of ADHD In Young Children
- ADHD most common mental disorder in childhood, 4-7% of children
- Affects 2% of children aged 3 to 5 years
- Preschoolers with ADHD are at risk for difficulties with math, reading, fine motor skills.
- There are reasonable data regarding methylphenidate in preschoolers
- Dosing 2.5 mg to 30 mg per day
- No studies of amphetamines regarding safety, efficacy in preschool aged children
- Ironically, methylphenidate is approved over age 6 years, amphetamines over age 3 years.
- PATS study
- Optimal dose relatively small, 14.2 mg/day
- All three doses improved symptoms in children who had already failed intensive parental training
- Medications not as well tolerated as in older children, lots of side effects
- Atomoxetine not well studied in this population, study coming out shortly.
- Use is off label
- Clear improvement on the ADHD Core Rating Scale, but many remained symptomatic
- Beaded methylphenidate in 4 to 5 year old children (Ritalin LA)
- Effective, but high drop-out rate from side effects
- Guidelines in Journal of the American Academy of Child and Adolescent Psychiatry, 2007; 46
- Assessment
- Multiple visits
- Multiple informants
- Multidisciplinary team if possible
- Look at parental issues, emotional and behavioral symptoms, developmental history
- Consider non-pharmacologic treatments first
- Start with psychotherapy
- Even when pharmacologic treatment is successful re-assess need for meds every six months.
- Minimal behavioral intervention 8 weeks
- Order of pharmacologic intervention
- Methylphenidate
- Amphetamine
- Atomoxetine or alpha agonist
- Disruptive Behavior Disorders
- Make sure you’ve assessed and treated other disorders first
- Trial of non-pharmacologic interventions
- Risperdone is the main pharmacologic intervention
- Depression
- We have almost no data on how to treat depressed preschoolers
- So start with non-pharmacologic therapies
- Anxiety Disorders
- PTSD responds to psychotherapy based on good studies
- Medications are not indicated for PTSD in preschoolers
- Start wit non-pharmacologic treatments
- Try fluoxetine, then fluvoxamine
- OCD
- Start with cognitive behavioral therapy
- May try
- Fluoxetine
- Fluvoxamine
- Sertraline
- Primary Sleep Disorders
- Comprehensive assessment
- Non-pharmacologic interventions
- Melatonin
- Clonidine
Adolescent Issues in Adolescent Psychiatry, Adelaide Robb, MD
- Adolescent Onset Disorders
- Major Depression
- Bipolar Disorder
- Schizophrenia
- Criteria for Major Depression
- Two weeks of sad mood, anhedonia, loss of interest in activities they used to enjoy
- Significant weight change (loss or gain)
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or guilt
- Diminished ability to think or concentrate
- Criteria for Mania
- Grandiosity
- Decreased need for sleep
- Pressured speech
- Flight of ideas, racing thoughts
- Distractibility
- Increase in goal directed activity
- Excessive involvement in pleasurable activities
- Criteria for Schizophrenia
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized thinking
- Withdrawal
- Must last 6 months
- Exclude schizoaffective or mood disorder
- Exclude PCP, crystal meth, ketamine abuse
- Meningitis, encephalitis can present with psychotic symptoms
- SSRI’s
- Safer in overdose
- Escitalopram didn’t work in younger children, did work in older children and teens
- Only fluoxetine and escitalopram are FDA approved for depression in children
- More are approved for OCD, including fluoxetine, fluvoxemine
- Studies report effective use to treat social phobia
- May help in bulimia, anorexia for relapse prevention but may not work in the acute setting
- Teens will stop medications for sexual side effects and they won’t tell you why.
- May also change GI patterns, may remember dreams and nightmares better
- SSRI’s may activate children especially when starting, titrating up.
- May see a manic episode in teens at risk for bipolar disorder
- Night sweats: may be side effect of SSRI’s
- May cause increased yawning
- Should not be combined with Imitrex, Maxalt, Zomig, etc.
- Atypical antipsychotics
- Aripiprazole (Abilify), Risperidone (Risperdal) approved by FDA, others not yet.
- Insurance companies push parents to use other, cheaper, less safe drugs like Clozaril.
- Aripiprazole
- Antagonist for serotonin 5-HT 2A, lowers prolactin levels
- Has a black box warning for suicidal thought, but not really justified by studies.
- Approved for depression, bipolar disorder, schizophrenia
- Data support use for autism with aggressive behavior, but not yet FDA approved.
- Risperidone
- More data in teens and younger children than any other atypical antipsychotic on the market
- May cause somnolence, dizziness, extra-pyramidal symptoms, weight gain
- FDA approved for autism, schizophrenia, bipolar disorder
- Most likely to elevate prolactin levels
- Can use IM form, lasts 2 weeks
- Side effects of antipsychotics
- Extra-pyramidal
- Anticholinergic
- Dystonia
- Withdrawal dyskinesia
- Cognitive dulling, affective blunting
- Lower seizure threshold
- Neuroleptic malignant syndrome, may be fatal, rare.
- Weight gain
- Priapism
- Elevations in cholesterol, triglycerides
- Black box warnings: suicidality, strokes (in the elderly)
- Clozapine not labeled for children, but many black box warnings for lethal side effects. DO NOT USE IT!
- Antipsychotics monitoring
- Baseline EKG
- Fasting glucose, lipids at baseline and 6 months
- Weight, height
- Menses
- Suicidal thoughts, attempts
The Care of Feeding Tubes, Jeffrey Lukish, MD
- Indwelling Catheters
- PICC very desirable
- Easily last up to three months
- Don’t damage major veins
- Very low infection rate
- Externalized Tunneled
- Broviac, Hickman, Groshong
- Good for therapy over 3 months duration
- Utilize Dacron duff for anchor, barrier
- Outpatient use is safe
- Child must be sedated for placement, removal
- Critical to document catheter size in order to repair one if broken (must repair with same size)
- Internalized implanted catheter
- Mediport, Port A Cath, Infuse A Port
- Must be placed in OR
- Does not limit activity at all
- Outpatient therapy safe
- Removal also requires anesthesia
- May last for years
- Infection rate 0.3 to 1.8 per 1000 days
- Checking patency of catheters
- MUST use at least a 5 ml syringe to check patency. Smaller syringes generate higher pressures, more likely to damage lines.
- Heparin flush needed with all central lines except Groshong
- Don’t use Betadine or Triple Antibiotic ointments - they dessicate the silicon of the port
- Use a Huber needle with ports, no other needle type - other needles make holes in the silicon of the port
- Use the standard clamp on catheters, not a hemostat
- Catheter Occlusions
- Start with an AP and lateral CXR - is the tip in the right position now? Can move.
- Try increasing venous pressure, Trendelenburg Position, Valsalva, arms over the head, cough
- Think precipitated medication: have to know what the last medication was.
- Specific solutions unclog specific medications
- Catheter: can inject but can’t aspirate
- Fibrin sheath thrombus
- TPA infusion, Alteplase
- Catheter: can’t infuse or aspirate
- Thrombus - TPA, Alteplase will still work
- Arm/Head/Neck edema
- Start with chest x-ray and ultrasound initially looking for azygous vein thrombosis.
- Catheter migration/displacement
- Externalized
- If obvious in the first one to two weeks replace cathter on a non-urgent basis
- Internalized
- Pain or edema during injection
- Catheter may become dismantled from port, cause an embolism
- Confirm with x-ray
- Replace urgently
- Catheter Leakage/Breakage/Disruption
- Internal
- Pain with infusion, erythema, or edema along the site
- Need to perform a catheter-gram to find the damage
- External fracture will present with wet dressing
- Clamp proximal to the fracture
- Any pediatrician should be able to repair a fractured catheter
- Catheter Infections
- Risk factors
- Time
- Tunneled versus non-tunneled
- Tie
- Premie
- Neutropenia
- Difficult initial placement.
- Antibiotic impregnated catheters help fro a few weeks
- Biopatch is useful,
- Better nursing care improves infecip
- Tunnel infection is defined as occurring two cm or greater under the skin
- Site infections will clear with treatment
- Tunnel infectious won’t clear
- Gastrostomy Tubes
- Nasogastric tubes
- Salem sump (replogle
- Kangaroo tubes
- Risks
- Aspiration
- Pneumonia
- Mucosali injury
- Sinusitis,
- Pharyngitis
- AOM
- Dislodgement
- Obstruction
- Should not stay in any longer than a month
- G-tubes
- Place for complications from naso-gastric tube
- May not be a good choice for GERD in neurologically devastated child
- Percutaneous placement (PEG tube)
- Easy to traverse the colon on the way to the stomach
- Now use single port 5 mm endoscopy to visualize stomach, minimize complications
- Complications of G-tubes
- Dislodgment
- Early is in the first four weeks
- Needs to be replaced by skilled physician or nurse
- Consult the original service that placed the tube
- Late, after four weeks
- Start by testing button - should not take more than 5 ml of saline
- Put tube back in orifice
- Don’t use a Foley if you have the right kind of tube
- If you use a Foley tape it down so it doesn’t migrate!
- Obtain contrast study after replacement
- Obstruction
- Do not insert stylet
- Use warm water, soda instilled in tube
- May also use meat tenderizer
- May replace tube, but make sure tract is mature first
- Leakage
- It is NORMAL
- Dressings - keep site dry
- Check balloon, don’t over-inflate
- Examine site, make sure it’s not injured or infected
- Replace with smaller tube for a week to allow site to contract
- If site is good and there’s new leakage then get contrast study to make sure tube is in the right place.
- If possible do a g-tube holiday and allow oral feeds for two days to a week.
- Consider continuous feeds rather than bolus feeds
- Get a stoma nurse involved in following the child
- Granulation tissue
- To some extent this is normal
- Results from excess tube motion
- Try to rule out prolapse - contrast study, exam by original team
- Treat with silver nitrate, topical steroids, possibly excision
- Dermatitis/Cellulitis/Abscess
- Skin irritation is the initial event, try to immobilize tube
- Pain is the hallmark of dermatitis
- Treat with oral antibiotics, tube immobilization
- If treatment fails may require OR for I&D
- Jejunostomy tubes
- Rarely used
- Indicated for alteration of foregut, chronic aspiration pneumonia
- Dislodgment is a common problem with these tubes
- Replacement must be performed by specialist, very tricky
- Replacement is not a bedside procedure for the most part.
- Obstruction occurs more often than with G-tube
- Presents with nausea, emesis, abdominal distention
- Cecostomy tubes
- Used for intractable constipation, neurogenic bowel, anorectal malformations, spinal abnormalities
- Complications:
- Stenosis of the stoma - has to be dilated
- Dislodgment - not urgent
- Leakage - can use larger tube
Saving Lives: Early Recognition of The Critically Ill Child, Alice Ackerman, MD
- Ideally have written protocol about who does what in an emergency situation.
