AAP NCE 2009 Day #3

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.