1. Common Pediatric Issue: Headaches
Migraine and tension-type headache are two common headache disorders treated in a primary care setting. Twenty percent of primary care visits are related to headache.
Symptoms of tension headache:
- Dull, persistent, bilateral "pressure."
- Often associated with stress and fatigue.
- Non-progressive, the pain waxes and wanes.
- Generally not exacerbated by exertion.
- No nausea or vomiting, photophonophobia.
- May last 30 minutes to several days.
Symptoms of migraine headache:
- Pulsating pain, moderate-severe.
- Unilateral location (in children, may be bilateral).
- Aggravated by routine physical activity.
- Nausea and/or vomiting.
- Photophobia and/or phonophobia.
- Duration two to 48 hours.
Warning signs of dangerous headache:
- Night-time wakings.
- Early morning headaches.
- Focal neurologic signs.
- Papilledema, diplopia.
- Evidence of cranial trauma.
- Progressive symptoms.
Workup for secondary headache:
- Neuroimaging (MRI, MRA).
- Connective tissue panel: TSH, T4, T3, CBC, ESR, Lyme titer, ANA, rheumatoid factor, HCG (prn).
- Lumbar puncture if pseudotumor cerebri, subarchnoid hemorrhage or infection are suspected.
- EEG if chronic paroxysmal headache without history of migraine.
When not to worry:
- Headache duration less than 6 months.
- Family history of migraine.
- Normal physical exam.
When to reconsider:
- Character of headache changes suddenly or progressively worsens over time.
- New neurological signs on exam.
- Headaches not managed by standard medications (3 prophylactic trials).
Treatment strategies
Abortive therapy is used as needed at onset of headache and optimal use is less than one time per week to avoid analgesia rebound headache. Prophylactic therapy is given daily for headaches that occur more than once per week, or that interfere with routine activities. Maximum benefit of prophylactic therapy may not been seen for six to 12 weeks. It is expected that treatment will last approximately six to 12 months.
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Abortive medications: |
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Doses: |
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Side effects: |
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Aspirin |
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15 mg/kg/4-6 hr |
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Bleeding; GI upset |
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Acetaminophen |
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15 mg/kg/4-6 hr |
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Nonsteroidal anti- drugs (NSAIDS)
i.e. ibuprofen |
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15 mg/kg/4-6 hr |
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Bleeding; GI upset inflammatory |
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Sumatriptan* |
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.06mg/kg SQ;
25-50 mg po
Also available as a nasal spray. |
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Shortness of breath |
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Zolmitriptan* |
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2.5-5 mg, repeat 2 hrs. |
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Shortness of breath |
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*Pediatric dosage, safety and efficacy has not yet been established. Approved for patients 18 years and older.
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Prophylactics: |
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Doses: |
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Side effects: |
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Amitriptyline |
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1-2 mg/kg/day |
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Sedation |
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Valproate |
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20-40 mg/kg/day |
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Weight gain, alopecia |
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Cyproheptadine |
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0.25 mg/kg/day |
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Sedation |
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Propranolol |
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2-4 mg/kg/day |
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Hypotension, GI |
To refer a patient:
Pediatric Neurology:
(414) 456-4090 for headaches with neurological changes/abnormal exam findings, difficult to treat headaches, or at parent/clinician preference.
To make an appointment:
Central Scheduling:
(414) 607-5280 or (877) 607-5280.
Sources: Tammy M. Fennig, RN, MS, CPNP, Pediatric Neurology, Children's Hospital of Wisconsin; and Mary Zupanc, MD, medical director, Neurology, Children's Hospital of Wisconsin, associate professor and chief of the division of Pediatric Neurology, Medical College of Wisconsin.
2. Common Pediatric Issue: Constipation
Constipation is the chief complaint in three percent of all pediatric outpatient visits and up to 25 percent of children seen by pediatric gastroenterologists. Constipation is a symptom, not a disease or a sign, and it may be caused by many different disorders. Only a small fraction of children have organic or anatomic causes for constipation. In the majority of children with constipation, the cause is a functional or behavioral problem.
The most common, non-organic cause of constipation in children is functional fecal retention, also known as psychogenic megacolon or idiopathic constipation. This is the voluntary retention of stool secondary to the fear of defecation.
Features of Functional Fecal Retention
Functional fecal retention is particularly common during toilet training and at the start of the school years. Placement of a high premium on avoiding "accidents" can cause a toddler to voluntarily retain stool. Alternatively, experience with painful defecation may increase fear of defecation. Features to look for include:
- Hard stools.
- Anal fissure.
- Perianal infection.
- Sexual abuse (large fissures, patulous anus, venereal warts are suggestive, but not diagnostic, for sexual trauma).
- Urinary tract infection (5 percent to 10 percent of chronically constipated children will have UTI).
- Fecal soiling.
Features of Anatomic Disorders Causing Constipation
Anatomic causes of constipation are encountered less frequently in general practice. Diagnosis usually can be accomplished by history and physical examination. The most common anatomic causes of constipation in children include:
- Hirschsprung's disease (intestinal aganglionosis).
- Imperforate anus or anteriorly displaced anus.
- Meconium ileus secondary to cystic fibrosis.
- Anal stenosis.
- Occult spinal dysraphism; myelomenigocele.
- Rectal polyp or mass.
Treatment
Functional fecal retention is best viewed as an acquired behavior in which the affected child has "forgotten" the mechanics of defecation. Physicians and parents should help the child understand that responding to an urge to defecate and not holding back is the key to success. Physicians should provide guidance and assure painless defecation by providing stool softeners. Agents most commonly used include lubricants such as mineral oil, osmotic agents such as lactulose or milk of magnesia, and stimulants such as bisacodyl or senna derivatives. The role of dietary fiber in the treatment of functional fecal retention remains controversial. Older children may be assisted with focused biofeedback aimed at helping them learn how to relax or contract the external anal sphincter. Treatment failure occurs in approximately 20 percent of children with functional fecal retention, particularly if symptoms have been present for several years.
Anatomic abnormalities of the anus and rectum, including Hirschsprung's disease, should be evaluated by a pediatric surgeon. Most, if not all, anatomic causes of constipation are amenable to surgical correction of the congenital defect or improving the quality of life. (For example, daily administration of antegrade colonic enemas through a cecostomoy to improve defecation patterns in children with myelomeningocele).
For more information:
Pediatric Gastroenterology clinic
Children's Hospital of Wisconsin
(414) 266-3690
Pediatric Surgery
Children's Hospital of Wisconsin
(414) 266-6550
American Academy of Pediatrics
(847) 434-4000
www.aap.org
Rudolph editor of leading pediatric textbook
In addition to his clinical practice, which attracts patients from all over the world, Colin Rudolph, MD, PhD, is editor of Rudolph's Pediatrics, a widely used textbook in U.S. medical schools and overseas. Rudolph's Pediatrics is in its 21st edition and it has been translated into multiple languages, including Japanese, Greek and Spanish. Rudolph joined the staff of Children's Hospital of Wisconsin in 2001. He came from Children's Hospital of Cincinnati.
3. Pediatric Research: Sedation
Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model.
George Hoffman, MD, Rhonda Nowakowski, Todd Troshynski, MD, Richard Berens, MD, Steven Weisman, MD, Department of Anesthesiology, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin. ghoffman@mcw.edu
This study reports on complications of pediatric sedation following implementation of a uniform sedation process at a children's hospital. The study concluded that complications of deep sedation were significantly higher than those of conscious sedation, but could be reduced by assessment of specific risk factors, use of tools to measure sedation depth, and adherence to guidelines of the American Academy of Pediatrics and the American Society of Anesthesiologists. For detailed study results, see http://www.pediatrics.org/cgi/content/full/109/2/236.
Primary study finding
This study showed that an adherence to guidelines for a structured sedation process reduces adverse events.
Elements most important for risk reduction include:
- Use of the guided risk assessment tool to identifying known risk factors for physiologic deterioration, particularly obstructed breathing.
- Regular, repeated use of a sedation scoring system to assess the depth of sedation.
- The single most important predictor of adverse events was a failure to complete a risk assessment.
- Performance of a risk assessment reduced the complications of deep sedation.
- Sedation scoring reduced the risk of excessively deep sedation.
- Midazolam emerged as the drug of choice for moderate sedation.
- Adverse events were lower with midazolam than with opioids or opioid-hypnotic combinations.
- Adverse events were highest with chloral hydrate, contrasting with widespread perceptions about its safety.
- Combinations of three or more drugs resulted in a higher complication rate, reinforcing the previously reported risks of opioid-sedative combinations, particularly fentanyl.
Improving sedation results
These steps have been found to improve sedation at Children's Hospital of Wisconsin:
- Complete pre-sedation assessment of risk factors including questions about snoring.
- Have enough trained individuals to do the procedure and to monitor the patient.
- Use pulse oximetry, repeated sedation depth scoring, and continuous assessment of respiration and circulation.
- Continue monitoring until peak drug effect has passed and the patient is fully awake.
The Children's Hospital of Wisconsin sedation record prompts the complete sedation process. A copy of this can be obtained by contacting Nancy Paffel at npaffel@chw.org.
For additional information see these online resources:
4. New programs and services
Level I Trauma Center
Children's Hospital of Wisconsin has received designation as a Level I trauma center from the American College of Surgeons, making it one of only 14 such centers in the country dedicated to the care and treatment of children.
NICU expansion under way
The Neonatal Intensive Care Unit at Children's Hospital of Wisconsin is undergoing a total reconstruction. The unit has been operating at near capacity for several years and 20 additional beds will be available May 15. An open house and tour of the new facility are being planned for Friday, May 10.
Poison Center
In February 2002, a new national number was implemented for poison information and referral. Children's Hospital is the designated poison center in Wisconsin and receives more than 45,000 calls from medical providers and families. Staff identify possible poisons, provide information on how to handle ingestions and exposures, and refer callers to appropriate health care providers. To reach the center, call (800) 222-1222.
Pediatric information online
More than 4,000 pages of pediatric-specific Web site content has been added to the Children's Health System site, www.chw.org. Physicians and patients will find detailed information about more than 30 topic areas from asthma/allergy to urology.
Child Advocacy Center opens in Kenosha
Child protection services, including expert medical exams for abuse, neglect and foster care now are available at Children's Hospital of Wisconsin-Kenosha Child Advocacy Center, Medical Professional Building, Suite 3090, 6308 8th Ave., Kenosha, (262) 653-2266.
New pediatric specialty clinic in Kenosha
In addition to the Gurnee, Ill. pediatric specialty clinic that has been available for several years, Children's Hospital of Wisconsin-Kenosha has opened a new facility to provide care to patients in southeastern Wisconsin and northern Illinois. The new clinic, located at Kenosha Hospital and Medical Center in the Medical Professional Building, Suite 3090, 6308 8th Ave., Kenosha, is staffed by a number of rotating specialists including a neurologist. Pediatric Cardiology services are available in Suite 3030. Call (262) 656-8895. For information about other specialties available, call (262) 653-2260.
Fox Valley clinic moves
Children's Hospital of Wisconsin Clinics-Fox Valley has moved to Theda Clark Medical Center, 130 2nd Street, Suite 198, Neenah. Current pediatric specialists on-site include asthma/allergy, cardiology, endocrinology, gastroenterology, and general surgery. To reach the clinic, call (920) 969-7970.
5. Medical staff additions
Joan C. Arvedson, PhD
Program coordinator, Feeding and Swallowing Services, Children's Hospital of Wisconsin; professor, Pediatrics, Medical College of Wisconsin; member, Children's Specialty Group. Emphases: gastroenterology, feeding and swallowing. Graduate School: University of Wisconsin, 1986. Clinic: Milwaukee.
David P. Bick, MD
Pediatric geneticist, Children's Hospital of Wisconsin; associate professor, Pediatrics (Genetics), Medical College of Wisconsin; member, Children's Specialty Group. Emphases: clinical medical genetics and clinical molecular genetics. Board Certifications: Clinical Medical Genetics, Clinical Molecular Genetics, Pediatrics. Medical School: George Washington University, Washington, D.C., 1981. Clinic: Milwaukee.
Pamela Sayger, DO
Pediatric cardiologist, Children's Hospital of Wisconsin and Children's Hospital of Wisconsin-Kenosha; assistant professor, Pediatrics (Cardiology), Medical College of Wisconsin; member, Children's Specialty Group. Emphasis: Neonatalogy. Board Certification: Pediatrics. Medical School: Chicago College of Osteopathic Medicine, 1994. Clinics: Gurnee, Ill., Kenosha, Racine.
Janette Strasburger, MD
Pediatric cardiologist, Children's Hospital of Wisconsin; professor, Pediatrics (Cardiology), Medical College of Wisconsin; member, Children's Specialty Group. Emphases: syncope, exercise medicine, arrhythmia management. Board Certification: Pediatrics, Pediatric Cardiology. Medical School: University of Nebraska College of Medicine, 1980. Clinics: Neenah, Milwaukee.
Heidi Zafra, MD
Pediatric allergist/immunologist, Children's Hospital of Wisconsin; instructor, Pediatrics and Medicine, Medical College of Wisconsin; member, Children's Specialty Group. Emphases: allergic rhinitis, allergies, asthma, eczema, immune deficiency, immunology, immunotherapy, sinusitis, urticaria, venom allergy. Board Certification: Pediatrics. Medical School: University of the East College of Medicine, Manila, Philippines, 1990. Clinic: Milwaukee.
Mary Zupanc, MD
Pediatric neurologist and medical director of Neurology, Children's Hospital of Wisconsin; associate professor and chief of the Division of Pediatric Neurology, Medical College of Wisconsin; member, Children's Specialty Group. Emphases: autistic spectrum disorders, developmental disorders of central nervous system, electroencephalography (EEG), epilepsy, headaches, mitochondrial disorders, movement disorders, neuro-oncology, neurometabolic disorders, neuromuscular disorders, pediatric neurology, Tourette's Syndrome. Board Certification: Neurology, Pediatrics. Medical School: University of California, Los Angeles, 1977. Clinic: Milwaukee.
6. CME Program Schedule
Milwaukee
Grand Rounds
Held from 8:30 a.m. to 9:30 a.m. Fridays in the Children's Hospital of Wisconsin auditorium, 9000 W. Wisconsin Ave.
April 26 - THE LORI HAKER MEMORIAL LECTURE, "Emerging Tick-borne Zoonoses, Lyme Disease, Babesiosis and Human Granulocytic Ehrlichiosis," Peter J. Krause, MD, chief, Pediatric Infectious Diseases, Connecticut Children's Medical Center, Hartford, Conn.
May 3 – "Treatment of Obsessive Compulsive Disorder in Children and Adolescents," A.J. Allen, MD, PhD, senior clinical research physician, Lilly Research Labs, Eli Lilly & Co., Indianapolis.
May 10 – TBA.
May 17 – THE WILLIAM GALLEN LECTURE.
May 24 – "Nutritional Growth Failure," Fima Lifshitz, MD, chief, Nutrition Sciences, immediate past chief of staff, Miami Children's Hospital, Miami, professor of Pediatrics, State University of New York, Brooklyn.
May 31 – "Issues of Spirituality and Suffering in Pediatrics," Javier Kane, MD.
June 7 – "Type II Diabetes in Adolescence: Etiology, Diagnosis and Management," Arnold Slyper, MD, pediatric endocrinologist, Children's Hospital of Wisconsin, associate professor, Pediatrics (Pediatric Endocrinology), Medical College of Wisconsin.
June 14 – "Management of Asthma in the New Millennium," Robert A. Nathan, MD, clinical professor of Medicine, Department of Internal Medicine, Division of Allergy and Immunology, University of Colorado Health Sciences Center, Denver.
June 21 – "Spit Happens," Steven Werlin, MD, pediatric gastroenterologist, Children's Hospital of Wisconsin, professor, Pediatrics (Pediatric Gastroenter-ology), Medical College of Wisconsin; and Colin Rudolph, MD, medical director, pediatric
June 28 - MEET THE NEW INTERNS
Fox Valley
Programs are held at noon on the second Wednesday of each month at Appleton Medical Center and Children's Hospital of Wisconsin-Fox Valley.
May 8 – "The Cutting Edge of Pediatric Epilepsy Surgery vs. Designer Drugs," Mary Zupanc, MD, medical director, Pediatric Neurology, Children's Hospital of Wisconsin, professor, Neurology, Medical College of Wisconsin.
June 12 – "Inflammatory Bowel Disease in Pediatric Patients," Thomas Sato, MD, pediatric surgeon, Children's Hospital of Wisconsin, assistant professor, Surgery (Pediatric Surgery), Medical College of Wisconsin; and Subra Kugathasan, MD, gastroenterologist, Children's Hospital of Wisconsin,
Kenosha
Programs held at Kenosha Hospital and Medical Center.
May 1 – "Vagus Nerve Stimulation," Michael Hammer, MD, pediatric neurologist, Children's Hospital of Wisconsin Clinics – Gurnee.
June 5 – "When To Do Abdominal Surgery on a Child," John Aiken, MD, pediatric surgeon, Children's Hospital of Wisconsin, assistant professor, Surgery (Pediatric Surgery), Medical College of Wisconsin.
Waukegan
Programs held at Provena Saint Therese Medical Center.
May 10 – "Hypoplastic Left Heart Syndrome," Michele Frommelt, MD, pediatric cardiologist, The Heart Center, Children's Hospital of Wisconsin, assistant professor, Pediatrics (Cardiology), Medical College of Wisconsin.
June 14 – "Renal Tumors," – Joel Shilyanski, MD, pediatric surgeon, Children's Hospital of Wisconsin, assistant professor, Surgery (Pediatric Surgery), Medical College of Wisconsin.
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