Common pediatric issue: Bronchiolitis
Bronchiolitis is a viral infection of the upper and lower respiratory tract (medium and small airways). The peak incidence is in winter. Respiratory syncytial virus (RSV) accounts for approximately 80 percent of cases; parainfluenze, adenovirus, influenza and other respiratory viruses are less common causes. Children younger than 2 years old most commonly are affected.
Clinical features
- Nasal congestion and rhinorrhea.
- Cough.
- Wheezing and rhonchi.
- Central apnea (young infants).
Bronchiolitis begins as an upper respiratory infection. Over a period of several days, the lower tract becomes involved. Typically, signs and symptoms peak in severity on the third to fifth day of illness, then begin to wane. The total duration of the illness is generally 10 to 14 days, although some children may have prolonged courses, with 18 percent reported to be ill for at least 21 days.
Diagnostic testing
Bronchiolitis generally is diagnosed on the basis of clinical findings. Rapid RSV antigen testing (nasal swab) is available. Sensitivity of the commercially available tests is in the range of 80 to 90 percent, and specificity is greater than 90 percent. However, the clinical utility of this test is limited, since treatment is directed toward the clinical manifestations rather than the etiologic agent, and often will be the same regardless of the test results. RSV antigen testing is recommended only for cases in which the diagnosis is unclear. Chest X-ray is not indicated for routine cases. In a recent study, only one of 140 children with bronchiolitis had a finding that changed management (cardiac anomaly), and that finding was predicted on clinical grounds before the X-ray was taken.
Treatment
Management of infants with bronchiolitis is frustrating, as no highly effective therapies have been identified. Care is primarily supportive.
Supportive care:
- Nasal hygiene and suctioning.
- Supplemental oxygen, if needed.
- Intravenous fluids for infants whose respiratory distress leads to inadequate fluid intake.
- Monitoring for high-risk infants (see below).
Inhaled bronchodilators:
- Albuterol: This frequently is used for infants with bronchiolitis, but numerous clinical trials have shown it to be of limited effectiveness. A subset of infants may respond to inhaled albuterol, so an initial trial of one or two treatments is warranted, but treatment should not be continued if there is no significant response. Oral albuterol has not been shown to be effective.
- Inhaled epinephrine: Several studies have suggested that inhaled epinephrine may be of greater benefit than albuterol, but two recent studies have shown no benefit to either. Moreover, inhaled epinephrine is not available for home use. A trial of epinephrine may be considered for those infants who require hospitalization and who do not respond to albuterol.
Corticosteroids:
A recent study suggested dexamethasone may decrease hospitalization in infants with moderate to severe disease, but a number of other clinical trials have shown no benefit of either systemic or inhaled corticosteroids in infants with bronchiolitis. Steroids may be considered in select infants suspected of having intrinsic asthma, such as those with a strong family history of asthma, prior history of wheezing or atopic disease, and good response to inhaled albuterol. However, steroids currently are not recommended for routine use.
Hospitalization
Bronchiolitis is the most common reason for hospital admission among infants and young children, though the vast majority may be managed at home. Indications for hospitalization include:
- Hypoxia requiring supplemental oxygen.
- Dehydration/need for IV fluids.
- Apnea.
In addition, hospital admission may be considered for monitoring infants at high risk of severe disease and clinical deterioration. High-risk factors include:
- Prematurity (especially gestational age less than 34 weeks).
- Less than 1 month old.
- Severe tachypnea (RR>70).
- Presence of other underlying cardiac, pulmonary or neurologic disease.
Prevention
The use of a monoclonal anti-RSV antibody (palivizumab or Synagis) in high-risk infants has substantially reduced hospitalization rates.
Nosocomial spread of RSV infection is a potential problem in hospitalized infants. Proper isolation precautions for respiratory secretions and vigilant hand washing are crucial.
Source: Marc Gorelick, MD, is medical director of Emergency Services at Children's Hospital of Wisconsin. He also is associate professor of Pediatrics and Emergency Medicine at the Medical College of Wisconsin and a member of Children's Specialty Group.
Common pediatric issue: Knee injuries in the young athlete
Today's children increasingly are involved in sports, both organized and as free play. The intensity as well as the level of play has increased dramatically over the last two decades. Significant sports injuries traditionally seen in adults have been seen more and more in relatively young children. Knee injuries in young athletes tend to be more severe and the outcome more problematic.
It is important to review several facts concerning the musculoskeletal system in the growing child to help sort out these injuries. Anatomically, there are three growth plates around the knee: one at the distal femur, one at the proximal tibia and another at the proximal fibula. In children, ligaments tend to be stronger than bone, and both ligament and bone are stronger than the cartilaginous growth plate. This explains why growth plate injuries tend to be more common than ligament sprains in children.
Traumatic knee injuries can involve any one of the anatomic components in the area. This includes the quadriceps extensor mechanism, the ligaments around the knee, the medial or lateral menisci, articular cartilage, the subchondral bone and growth or physeal cartilage around the bone. These injuries can have a significant effect on the long-term function of the knee. It is paramount to make the correct diagnosis so that the appropriate treatment can be administered. A physeal injury, an anterior cruciate ligament tear or significant meniscal tear often can lead to prolonged disability, especially if it goes undiagnosed.
Initial evaluation
For acute injuries, the history is very important. Obtain as much detail as possible regarding the injury. What was the actual mechanism of injury? Was there an audible "pop" or "snap"? Did the child fall to the ground? Was the child able to walk unassisted? Did the child continue to play sports after the injury? Was there swelling, and how rapidly did it occur? When did the pain intensity reach its maximum?
Signs of a more severe injury are when a child hears an audible "pop" or "snap" at the time of the injury, falls to the ground, is unable to leave the field of play under his or her own power and is unable to return to play.
Start with inspection and palpation when examining the knee. Obvious deformities should be noted. Any knee with visible swelling has a significant injury. It is important to differentiate whether the swelling is in the soft tissues or from an intraarticular fluid collection. Intraarticular fluid accumulation is most prominent around the patella. With a large effusion, the knee range of motion is limited significantly and the knee tends to be very painful with motion or palpation. Ecchymosis, skin abrasions or obvious contusions can give a clue to the mechanism and area of injury.
Palpation can localize the injury to a specific region. Anterior knee pain usually involves an injury to the extensor mechanism (i.e. patellar dislocation). Medial or lateral knee pain usually involves a physeal injury, collateral ligament injury or bone contusions. The knee should be checked for active range of motion. In the acute setting, it is best to have the child move the knee by himself or herself. If the child is unable to move the knee to near full extension and at least 90 degrees of flexion, a severe injury needs to be considered. Depending on the level of pain around the knee, the individual collateral and cruciate ligaments can be checked for integrity. This often is quite difficult to do within the first three to five days after a severe injury. One simple test of relative integrity of the bone and the ligaments around the knee is to have the child actively lift the leg off the exam table without help. Sensations and muscle function should be checked at the knee or at the ankle and foot to make sure the knee injury has not significantly affected the rest of the extremity.
Radiographic evaluation
Most knee injuries warrant radiographic evaluation. Anterior, posterior and lateral X-rays are recommended. A sunrise view should be included for injuries involving the quadriceps mechanism, including patellar dislocation or subluxation of the knee. A notch view occasionally is needed but only if there is evidence of cruciate ligament damage or significant joint effusion.
Indications for radiographic evaluation:
- Severe pain.
- Visible deformity.
- Moderate to severe swelling.
- Joint effusion.
- Limited range of motion.
- Unable to bear weight.
Initial management: Immobilization of the injured areas is the mainstay of initial treatment. Effective splinting can reduce pain and prevent further injury. It also allows the child more mobility. A splint should be applied to any child who is unable to bear weight on the affected leg and does not have nearly full range of motion.
Options for splinting the knee include a knee mobilizer, posterior fiberglass or plaster splint held on with the use of an Ace wrap. An Ace wrap alone will not provide effective mobilization. If a child cannot walk without a significant limp or cannot fully bear weight, crutches will be needed. Crutches are recommended for most significant knee injuries.
Ice: Ice will help prevent further swelling. The most effective method is to place bags filled with ice water on both sides of the knee. Use a single layer of cloth between the ice water and the skin to prevent skin injury.
Rest and elevation: A child with significant knee swelling needs to keep the knee elevated and must restrict activity. In the case of severe swelling and pain, the child should not attend school or other activities until the swelling has decreased.
Compression: To reduce swelling, Ace bandages are appropriate. They should be snug, not tight. Use wrap from the foot up to at least mid-thigh. If the Ace wrap is increasing the pain or causing the foot to swell, it should be removed.
When to refer: Any child with visible deformity around the knee, presence of joint effusion or inability to bear full weight on the leg should be evaluated by a physician well-versed in the care of pediatric skeletal injuries.
A general orthopedic specialist should be able to assess the majority of sports injuries. However, physeal and ligament injuries around the knee are best handled by a pediatric orthopedic specialist. While an initial X-ray may be negative, a child still may have a severe injury. In general, a secondary assessment of the injury should be made within two weeks of the injury and initial evaluation. With any significant injury, the child should not participate in sports for at least two weeks. Returning to sports too quickly and without the appropriate protective therapy or brace can be dangerous.
Magnetic Resonance Imaging (MRI): MRI of the knee is an extremely useful took in evaluating pediatric knee injuries. It can be helpful in making an accurate diagnosis of the injury when X-rays are negative. An MRI should not be used as a primary tool for evaluation of a knee injury or as a substitute for a thorough evaluation with a complete history and physical. In general, a child or adolescent with a severe knee injury with a significant joint effusion should undergo an MRI to rule out meniscal or chondral injuries, which cannot be seen in an X-ray and are difficult to assess on examination.
Common injuries seen at the Sports Injury Clinic at Children's Hospital of Wisconsin include patellar dislocation or subluxation, distal femoral physeal fractures, ligament avulsions, anterior cruciate ligament ruptures, osteochondral fractures and meniscal tears.
Joint aspiration: Joint aspiration rarely is necessary in acute knee trauma. If a large joint effusion exists, an arthrocentesis may be needed. The joint fluid is examined to see if it contains fat globules, which indicate an intraarticular fracture. A thin, watery and clear fluid indicates a chronic inflammatory process. Hemarthrosis indicates meniscal or capsular tears. Occasionally joint aspiration can reduce pain by relieving intraarticular pressure. Unfortunately, the fluid often re-accumulated quickly and defeats the purpose of the aspiration. Joint aspiration in acute knee injury should not be done on a routine basis.
The Orthopedic Center
In the Orthopedic Center at Children's Hospital of Wisconsin, four pediatric orthopedic physicians are exposed regularly to a wide variety of pediatric orthopedic conditions and are adept at evaluating pediatric sports injuries. The Sports Injury Clinic, established in 1994, has exclusively treated pediatric patients with sports-related injuries. An on-site pediatric physical therapist understands the specifics of pediatric sports injuries and is fully trained in pediatric injury rehabilitation.
Source: Roger Lyon, MD, is an orthopedic surgeon as Children's Hospital of Wisconsin. He also is an associate professor of Orthopedic Surgery at the Medical College of Wisconsin and a member of Children's Specialty Group.
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
For an urgent referral:
Call the Orthopedic Center's Nurseline at (414) 266-2411. A nurse will return your call within 30 minutes.
Physical Medcine and Rehabilitation: Expanding to serve more special needs children
Fred Klingbeil, MD, the new medical director of Physical Medicine and Rehabilitation at Children's Hospital of Wisconsin, has established high-level goals, but they are goals he feels are extremely important to children with special needs.
"I want to develop a program unlike any other currently available to children with special needs and their families," said Klingbeil.
Klingbeil also is an assistant professor in the department of Physicial Medicine and Rehabilitation at the Medical College of Wisconsin. Klingbeil joined Children's Specialty Group (CSG) in August 2002 and was named CSG's Strategic Practice Unit (SPU) leader for Physical Medicine and Rehabilitation.
Klingbeil has a medical degree from Wayne State University School of Medicine, Detriot, and completed a residency at Children's Hospital of Michigan, Detroit.
With more than 20 years of experience in rehabilitative medicine, most recently at Cleveland Clinic Children's Hospital for Rehabilitation, Klingbeil is providing the vision to take the Children's Hospital of Wisconsin program to the next level.
In the United States, more than 4 million children are limited in their activities due to a chronic condition. This represents more than 7 percent of non-institutionalized children under 18 years of age. Although the child is most affected by his or her condition, the child's family and community are impacted as well.
"In many cases, diagnosing a child's condition and subsequent treatment is the easy part," Klingbeil said. "The next step - helping the child with disabilities to optimally perform and participate in personal, family and community activities - is a much greater challenge."
To help such children reach their full potential, Klingbeil said coordination of care is critical. Klingbeil plans to have his department orchestrate services provided by physicians and surgeons, as well as experts in diet, psychology, therapy, social work, case management and education, to make such services more easily accessible to families.
"I came to Children's Hospital of Wisconsin because of the reputation they have for providing excellent medical care to children," Klingbeil said. "As a physician who sees children with conditions that cross many specialties, the benefit of having everything under one roof is tremendous. If I can make the child and family's experience a little bit easier by coordinating their care, we have achieved our goal."
For more information
Physical Medicine and Rehabilitation
(414) 266-2560
To make an appointment
Central Scheduling
(414) 607-5280 or (877) 607-5280
Take a virtual tour of Children's Hospital of Wisconsin
A virtual tour has been added to the Children's Hospital of Wisconsin Web site (www.chw.org/virtualtours). Compared to other pediatric hospitals throughout the United States, this new virtual tour is quite comprehensive.
Three separate tours were created, with a total of 15 different scenes throughout the hospital. These tours include:
- Pediatric intensive care unit (PICU).
- Neonatal intensive care unit (NICU).
- Cardiac catheterization lab.
- ECHO lab.
- Stress lab.
- Patient room.
- Epilepsy monitoring unit.
- Operating room.
- Day surgery.
- Main lobby.
- Waiting room.
- School room.
- Playroom.
- NICU/PICU family area.
- Children's Hospital campus.
Twenty "hotspots" were added throughout the tours to highlight specific equipment, areas of interest and staff. When Web site visitors click on a "hotspot," the accompanying text changes to provide in-depth information about that item.
The virtual tour was created as an educational tool for patients, families and referring physicians, as well as a way to publicly demonstrate the state-of-the-art facilities, equipment and programs at Children's Hospital.
Out of area family accommodations program
Last year, Children's Hospital of Wisconsin had more than 1,600 inpatient and 12,000 outpatient visits by families from outside the five-county Milwaukee area. Children's Specialty Group worked with the Children's Hospital of Wisconsin Family Services department to develop a new accommodations program. This program will assist out-of-area families in making air travel arrangements, lodging reservations and other concierge-type services.
An agreement with Midwest Express Airlines to provide discounted air travel is being negotiated. Agreements are in place with two area hotels to allow Children's Hospital to provide significantly-reduced room rates. To receive the discounts, these must be booked through Family Services. Family Services also can help families in financial need secure complimentary air travel though several airlines and private/charitable organizations.
One of the key benefits of the accommodations program is that Family Services makes all of the necessary arrangements for the families who want or need their assistance. This relieves families of the stress that may accompany making arrangements to travel to Children's Hospital, enabling them to concentrate on helping their children get better.
Although this program still is in a testing stage with the Neurology department, the program is expected to be rolled out throughout Children's Hospital and the specialty clinics in the next few months.
Physician notes
Medical director named
Wendy Hill, MD, was named medical director of the Hospitalist Program at Children's Hospital of Wisconsin-Fox Valley.
The Hospitalist program is designed to improve patient care and to assist primary care physicians whose patients are hospitalized. It is staffed by general pediatricians who are experts in inpatient care and who regularly update and consult with the patient's primary care physician. In addition to Hill, there are four pediatric hospitalists.
Special foundation chair selected
Calvin Williams, MD, PhD, was named the D.B. Marjorie Reinhart Family Foundation Chair in Pediatric Rheumatology at Children's Hospital of Wisconsin. He is a pediatric rheumatologist at Children's Hospital, and an associate professor of Pediatrics and Chief of Pediatric Rheumatology at the Medical College of Wisconsin.
Society of Pediatric Research members elected
The following specialists were elected to membership in the Society for Pediatric Research: Marc H. Gorelick, MD, MCSE, medical director of Emergency Services at Children's Hospital of Wisconsin, and chief and associate professor of Pediatrics (Emergency Medicine) at the Medical College of Wisconsin; David Margolis, MD, oncologist and medical director of the Bone Marrow Transplant Program at Children's Hospital of Wisconsin and associate professor of Pediatrics (Hematology and Oncology) at the Medical College; and Ramesh Sachdeva, MD, PhD, MBA, vice president of Quality and Outcomes for Children's Hospital of Wisconsin, executive vice president and chief operating officer of the National Outcomes Center, and associate professor of Pediatrics (Critical Care) at the Medical College.
Palliative Care fellowship program awarded funding
Children's Hospital of Wisconsin, in conjunction with Froedtert Hospital as Medical College of Wisconsin Affiliated Hospitals, has received $150,000 to fund a combined fellowship in pediatric and adult palliative care medicine. This fellowship program is among only seven others in the nation to receive a grant awarded by the Open Society Institute's Project on Death in American and the Emily Davie and Joseph S. Kornfield Foundation. In addition, it is one of the few fellowship programs across the country to accept pediatricians.
"Palliative care in a large academic pediatric medical center like ours is critical to providing compassionate and skilled care for children who are facing life-threatening or life-limiting illnesses," said Bruce Himelstein, MD, palliative care program director at Children's Hospital of Wisconsin and associate professor of Pediatrics at the Medical College of Wisconsin. "Children are not small adults, and require very specialized care from pediatric experts who understand the physical and emotional problems unique to children. Every day we apply complex knowledge of development of mind, body and spirit to help children and families restore wholeness in their toughest times."
Himelstein is project leader for the fellowship.
The Jane B. Pettit and Palliative Care Center at Children's Hospital is one of the largest academic pediatric palliative care programs in the country. Staffed by expert physicians and nurses, and supported by a large network of interdisciplinary care providers throughout the health care system, the program provides clinical services in the hospital and in the community 24 hours a day, seven days a week. There is an active research program and a rapidly growing educational agenda including training of students, residents and fellows.
2002 New Children's Specialty Group Physicians
Alan Adler, MD (Pediatric Pulmonology)
Kimberly J. Anderson, Psy D (Anesthesiology)
Anthony Balcom, MD (Pediatric Urology)
Mir Basir, MD (Neonatology)
David Bick, MD (Genetics)
Charles Durkee, MD (Pediatric Urology)
Glenn Flores, MD, FAAP (Pediatrics)
Charlene (Charlie) Gaebler-Uhing, MD (Hospitalist)
Edward Guillery, MD (Pediatric Nephrology)
Anne Joseph, MD (Pediatric Neurology)
Fred Klingbeil, MD (Physical Medicine and Rehabilitation)
Ndidiamaka Musa, MD (Critical Care)
Nalin Patel, MD (Pediatric Otolaryngology)
Diane Plantz, MD (Pediatric Emergency Medicine)
Diana R. Quintero, MD (Pediatric Pulmonology)
Kimberly M. Rennie, PhD (Neuropsychology)
Pamela Sayger, DO (Pediatric Cardiology)
Michael Stephens, MD (Pediatric Gastroenterology)
Martha (Molly) Stevens, MD, MSCE (Pediatric Emergency Medicine)
Janette Strasburger, MD (Pediatric Cardiology)
Tatyana Strong, MD (Pediatric Anesthesiology)
Channing Tassone, MD (Pediatric Orthopedics)
Michael R. Uhing, MD (Neonatology)
Calvin Williams, MD, PhD (Pediatric Rheumatology)
Steven Zangwill, MD (Pediatric Cardiology)
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