Pediatrics in Review

Cover credits:The artwork on the cover of this month's issue is by one of the
winners of our 2007 Cover Art Contest, 10-year-old Guillermo Sicard of North
Canton, Ohio. Guillermo's pediatrician is Jennifer Kungle, MD.
Vol. 29, No. 6; June, 2008

Editor-in-Chief: Lawrence F. Nazarian,
Rochester, NY
Associate Editors: Tina L. Cheng,
Baltimore, MD
Joseph A. Zenel, Portland, OR
contents
Editor, In Brief: Henry M. Adam, Bronx, NY
Consulting Editor: Janet Serwint, Baltimore, MD
Consulting Editor Online and Multimedia
PediatricsinReview姞 Vol.29 No.6 June 2008
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Editorial Office: Department of Pediatrics
183 Vomiting in Children:

University of Rochester
School of Medicine & Dentistry
601 Elmwood Avenue, Box 777 Reassurance, Red Flag, or Referral?
Rochester, NY 14642
sydney_sutherland@urmc.rochester.edu Latha Chandran, Maribeth Chitkara
Editorial Board
Margie Andreae, Ann Arbor, MI Hal B. Jenson, Springfield, MA
Richard Antaya, New Haven, CT Chris P. Johnson, San Antonio, TX
Laurence A. Boxer, Ann Arbor, MI J. Jeffrey Malatack, Narberth, PA
193 Complementary,
Latha Chandran, Stony Brook, NY
Joseph Croffie, Indianapolis, IN
Blaise Nemeth, Madison, WI
John Pascoe, Dayton, OH
Holistic, and Integrative
Howard Eigen, Indianapolis, IN
Leonard Feld, Charlotte, NC
DeWayne Pursley, Boston, MA
Thomas T. Sato, Milwaukee, WI Medicine: Therapies for Acute Otitis Media
Jeremy N. Friedman, Toronto, ON Bennett A. Shaywitz, New Haven, CT
Vincent A. Fulginiti,Tucson, AZ Michael Silberbach, Portland, OR Cecilia Bukutu, Janjeevan Deol, Sunita Vohra
Mark Goldstein, Boston, MA Nancy Spector, Philadelphia, PA
Lindsey Grossman, Baltimore, MD Surendra K. Varma, Lubbock, TX
Russell J. Hopp, Omaha, NE Maximilian Zach, Graz, Austria
Publisher: American Academy of Pediatrics
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212 Meconium Aspiration
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214 Emetics, Cathartics, and Gastric Lavage
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Disclosures
● Richard Antaya, MD, FAAP, disclosed that he participates in the Astellas Pharma,
US, Inc., speaker bureau, advisory board, and clinical trials, and in the Novartis
speaker bureau.
Internet-Only Article
● Laurence Boxer, MD, FAAP, disclosed that he owns Amgen stocks.
● Joseph Croffie, MD, MPH, FAAP, disclosed that he has research grants from
Abstract appears on page 200.
Sucampo Pharmaceuticals (Lubiprostone), Medtronics (Bravo pH Capsule), and
TAP pharmaceuticals (Prevacid), that he is on a Medtronics Advisory Board, and
that he serves on a speaker bureau for TAP.
e35 The Difficult Pediatric Encounter:

● Howard Eigen, MD, FAAP disclosed that he serves on speaker bureaus of Astra
Zeneca, Merck, GlaxoSmithKline, and TEVA, and that he is a consultant for
TEVA and Astra Zeneca.
● Leonard Feld, MD, MMM, PhD, FAAP, disclosed that he is a speaker for and
Insights and Strategies for the Pediatric Practitioner
committee member of a Pediatric Board Review Course (sponsored by Abbott
Nutrition) through the AAP New York Chapter. Andrea Gottsegen Asnes, Ambika Shenoy
● Jeremy N. Friedman, MD, CHB, FAAP, disclosed that he serves on the Medical
Advisory Board of the Proctor & Gamble Pampers Parenting Institute.
● Lindsey K. Grossman, MD, FAAP, disclosed that she is a consultant for Integra
Case Management.
● Russell J. Hopp, DO, FAAP, disclosed that he serves on speaker bureaus of
Astra-Zeneca, GlaxoSmithKline, Schering-Plough, and Sanofi-Aventis.
● Hal B. Jenson, MD, MBA, FAAP, disclosed that he is a speaker and vaccine
advisory board member for Merck Vaccines as well as a speaker for Sanofi
Pasteur.
● J. Jeffrey Malatack, MD, FAAP, disclosed that he is a member of the American
Board of Pediatrics.
● Bennett A. Shaywitz, MD, FAAP, disclosed that he is a speaker/consultant for
Eli Lilly Co.
● David L. Skaggs, MD, FAAP, disclosed that he is a consultant, speaker, and
research grant recipient of Medtronics, Stryker Spine.
● Surendra Varma, MD, FAAP, disclosed that he is on McKesson’s Professional
Advisory Board for Texas Medicaid and on the speaker bureau of Pfizer Corp.
The printing and production of Pediatrics in Review威 is

made possible, in part, by an educational grant from Cover: The artwork on the cover of this month’s issue is
Abbott Nutrition. by one of the winners of our 2007 Cover Art Contest,
10-year-old Guillermo Sicard of North Canton, Ohio.
Guillermo’s pediatrician is Jennifer Kungle, MD.
Answer Key: 1. D; 2. B; 3. E; 4. B; 5. C
Article gastrointestinal
Vomiting in Children:
Reassurance, Red Flag, or Referral?
Latha Chandran, MD,
Objectives After completing this article, readers should be able to:
MPH,* Maribeth Chitkara,
MD† 1. Discuss the most common causes of vomiting in children of different age groups.
2. Understand the physiology behind the process of vomiting.
3. Recognize common causes of vomiting based on the pattern and nature of emesis.
Author Disclosure 4. Be familiar with the basic diagnostic evaluation and treatment strategies for different
Drs Chandran and causes of vomiting.
Chitkara have
disclosed no financial
relationships relevant Case Study
A 1-month-old boy who has had postprandial vomiting for 1 week is admitted from the
to this article. This
emergency department. He was born at term with no complications and had regained his
commentary does
birthweight by the second week after birth, feeding on a milk protein formula. He has been
contain a discussion vomiting curdled milk intermittently for the past week, and on the day of admission was noted
of an unapproved/ by his pediatrician to have lost 4 oz in weight since his last check-up.
investigative use of a On physical examination, the infant is slightly lethargic and has a sunken fontanelle. The
commercial product/ rest of his physical examination findings, including evaluation of his abdomen, are normal.
Abdominal ultrasonography shows normal width and length of the pylorus. However, no food
device.
movement past the pylorus is observed. An echogenic density in the prepyloric area is noted. An
upper gastrointestinal (GI) radiographic series and endoscopy reveal an antral web, which is
excised surgically.
Physiology of Vomiting
Vomiting involves the forceful expulsion of the contents of the stomach and is a highly
coordinated, reflexive process. It is a feature of many acute and chronic disorders,
including those causing increased intracranial pressure, metabolic diseases, and anatomic
and mucosal GI abnormalities. Descent of the diaphragm and constriction of the abdom-
inal musculature on relaxation of the gastric cardia force gastric contents back up the
esophagus. The process is coordinated by the “vomiting center” in the central nervous
system. The vomiting center receives sensory input from the vestibular nucleus (cranial
nerve VIII), the GI tract via vagal afferents (cranial nerve X), and the bloodstream via the
area postrema, also known as the chemoreceptor (or chemoreceptive) trigger zone. The
stereotypic behaviors associated with emesis are a result of output from the vomiting center
through vagal, phrenic, and sympathetic nerves.
Types of Vomiting
Vomiting can be classified according to its nature and cause as well as by the character of
the vomitus. The nature of the vomiting may be projectile or nonprojectile. Projectile
vomiting refers to forceful vomiting and may indicate increased intracranial pressure,
especially if it occurs early in the morning. Projectile vomiting also is a classic feature of
pyloric stenosis. Nonprojectile vomiting is seen more commonly in gastroesophageal
reflux. These somewhat arbitrary descriptions are not definitive in establishing a diagnosis.
Emesis often is classified based on its quality. The vomitus may be bilious, bloody, or
nonbloody and nonbilious. Emesis originating from the stomach usually is characterized as
being clear or yellow and often contains remnants of previously ingested food. Emesis that
*Editorial Board.
†
Assistant Professor of Pediatrics and Emergency Medicine, Pediatric Hospitalist, State University of New York at Stony Brook,
Stony Brook, NY.
Pediatrics in Review Vol.29 No.6 June 2008 183

gastrointestinal vomiting
is dark green is referred to as bilious because it indi- loops and air-fluid levels, which strongly suggest bowel
cates the presence of bile. Bilious vomiting frequently is obstruction. Contrast imaging studies are more specific
pathologic because it may be a sign of an underlying and can help pinpoint a precise diagnosis. Surgical and
abdominal problem such as intestinal obstruction be- neonatal consultations should be obtained urgently
yond the duodenal ampulla of Vater, where the com- when the diagnosis of bowel obstruction is considered.
mon bile duct empties. The presence of blood in the
emesis, also known as hematemesis, indicates acute
Intestinal Atresias
bleeding from the upper portion of the GI tract, as can
Intestinal atresias are surgical emergencies and typically
occur with gastritis, Mallory-Weiss tears, or peptic ulcer
present within a few hours after birth. Duodenal atresia is
disease. Coffee ground-like material often is representa-
a congenital obstruction of the second portion of the
tive of an old GI hemorrhage because blood darkens to a
duodenum that occurs in 1 per 5,000 to 10,000 live
black or dark-brown color when exposed to the acidity of
births and is associated with trisomy 21 in approximately
the gastric secretions. The more massive or proximal the
25% of cases. It is believed to be due to a failure of
bleeding, the more likely it is to be bright red.
recanalization of the bowel during early gestation. In-
fants present with clinical features of failure to tolerate
Differential Diagnosis
feedings and bilious emesis shortly after birth. Due to the
A variety of organic and nonorganic disorders can be
proximal nature of the obstruction, abdominal disten-
associated with vomiting. Organic causes are those re-
tion usually is not present. Plain abdominal radiographs
lated to specific medical conditions. The primary care
may show a “double bubble” sign, which represents air in
practitioner needs to remember that vomiting does not
the stomach and proximal duodenum (Fig. 1).
localize the problem to the GI system in young infants
More distal obstructions, such as jejunoileal atresias,
but can be a nonspecific manifestation of an underlying
typically present with bilious vomiting along with ab-
systemic illness such as a urinary tract infection, sepsis, or
dominal distention within the first 24 hours after birth.
an inborn error of metabolism. Nonorganic causes are
The cause of these atresias is believed to be a mesenteric
much more difficult to identify and often are viewed as
vascular accident at some point during the course of
diagnoses of exclusion. Examples of nonorganic causes
gestation. The frequency of their occurrence is approxi-
of vomiting are psychogenic vomiting, cyclic vomiting
mately 1 per 3,000 live births. Anatomically, jejunoileal
syndrome, abdominal migraine, and bulimia. Table 1
atresias can be classified into four types: membranous,
lists the differential diagnosis of vomiting based on organ
interrupted, apple-peel, and multiple. Abdominal radi-
systems. However, from a clinical perspective, it often is
ography may show dilated loops of small bowel with
useful to consider causes from an age-related perspective.
air-fluid levels (Fig. 2). Urgent surgical correction is
necessary for all types of intestinal atresias.
Vomiting in Infancy
Table 2 details the age-related differential diagnosis of
vomiting in infants. Vomiting in the first few days after Malrotation With Midgut Volvulus
birth may be a sign of serious pathology. Bilious emesis is Understanding malrotation requires a review of the
suggestive of congenital obstructive GI malformations, organogenesis of the gut. During the third week of fetal
such as duodenal/jejunal atresias, malrotation with mid- development, the primitive gut is divided into three
gut volvulus, meconium ileus or plugs, and Hirsch- regions: the foregut, midgut, and hindgut, based on
sprung disease. Published reports of neonates evaluated vascular supply. The first stage of intestinal development
in neonatal intensive care units with a principal diagnosis involves rapid growth of the midgut outside the abdom-
of bilious emesis revealed that 38% to 69% had an intes- inal cavity through a herniation of the umbilical orifice.
tinal obstruction. (1) Nonsurgical causes of bilious eme- During the second stage, the midgut returns to the
sis include necrotizing enterocolitis and gastroesopha- abdominal cavity, rotating 180 degrees and pushing the
geal reflux (GER). hindgut to the left. The last stage of intestinal develop-
When caring for a neonate who has persistent bilious ment involves the retroperitonealization of portions of
vomiting, the clinician should place a nasogastric or the right colon, left colon, duodenum, and intestinal
orogastric catheter to decompress the stomach and pre- mesentery, helping them serve as anchors for the bowel.
vent any additional vomiting or aspiration before initiat- Disruption of this process during the second or third
ing any diagnostic or therapeutic maneuvers. Plain radio- stage can result in an aberrant return or anchoring of the
graphs of the abdomen can demonstrate dilated bowel midgut within the abdominal cavity.
184 Pediatrics in Review Vol.29 No.6 June 2008

Table 1. Differential Diagnosis of Vomiting by Systems

Gastrointestinal Neurologic Endocrine
● Esophagus: Stricture, web, ring, ● Tumor ● Diabetic ketoacidosis
atresia, tracheoesophageal ● Cyst ● Adrenal insufficiency
fistula, achalasia, foreign body ● Hematoma
● Stomach: pyloric stenosis, web, ● Cerebral edema Respiratory
duplication, peptic ulcer, ● Hydrocephalus ● Pneumonia
gastroesophageal reflux ● Pseudotumor cerebri ● Sinusitis
● Intestine: duodenal atresia, ● Migraine headache ● Pharyngitis
malrotation, duplication, ● Abdominal migraine
intussusception, volvulus, ● Seizure Miscellaneous
foreign body, bezoar, pseudo-obstruction, ● Meningitis ● Sepsis syndromes
necrotizing enterocolitis ● Pregnancy
● Colon: Hirschsprung disease, Renal
● Rumination
imperforate anus, foreign body, bezoar ● Obstructive uropathy: Ureteropelvic ● Bulimia
● Acute gastroenteritis junction obstruction, ● Psychogenic
● Helicobacter pylori infection hydronephrosis, nephrolithiasis ● Cyclic vomiting syndrome
● Parasitic infections: ascariasis, giardiasis ● Renal insufficiency
● Overfeeding
● Appendicitis ● Glomerulonephritis
● Medications/vitamin/drug toxicity
● Celiac disease ● Urinary tract infection
● Superior mesenteric artery
● Renal tubular acidosis
● Milk/soy protein allergy syndrome
● Inflammatory bowel disease Metabolic ● Child abuse
● Pancreatitis
● Galactosemia
● Cholecystitis or cholelithiasis
● Hereditary fructosemia
● Infectious and noninfectious hepatitis
● Amino acidopathy
● Peritonitis
● Trauma: Duodenal hematoma ● Organic acidopathy
● Urea cycle defects
● Fatty acid oxidation disorders
● Lactic adidosis
● Lysosomal storage disorders
● Peroxisomal disorders
Although most infants who have intestinal malrota- malposition of the superior mesenteric vessels. Timely
tion present within the first week after birth due to the surgical correction with the Ladd procedure is critical. If
accompanying volvulus, the malrotation itself does not bowel ischemia is prolonged, loss of bowel and resultant
cause any notable symptoms and may be undetected for short gut syndrome may occur.
years. Bowel strangulation can occur at any age and any
time because affected patients are at increased risk of Vomiting in Infancy Beyond the Neonatal
volvulus due to a lack of proper mesenteric anchoring to Period
the retroperitoneum. The midgut twists in a clockwise The differential diagnosis of vomiting in infants beyond
direction around the superior mesenteric vessels, leading the neonatal period is more extensive. Common causes
to obstruction of vascular supply to most of the small and are acute gastroenteritis, GER, and nutrient intolerances
large intestine. Once bowel ischemia occurs, metabolic such as milk or soy protein allergies. Metabolic diseases
acidosis, unstable hemodynamics, and intestinal necrosis and inborn errors of metabolism also should be consid-
with perforation may ensue if the condition is not diag- ered for infants who have persistent progressive vomit-
nosed and rapidly corrected surgically. A spiral configu- ing. Acquired or milder intestinal obstructive lesions,
ration of the jejunum or demonstration of failure of such as infantile hypertrophic pyloric stenosis (IHPS),
contrast to pass beyond the second portion of the duo- also are possible and should be ruled out when clinically
denum on upper GI radiographic series is diagnostic indicated.
(Fig. 3). Abdominal ultrasonography also may reveal a Common entities such as GER, dietary protein intol-

Age-related Differential Diagnosis of Vomiting in Children

Table 2.
Younger Than12 Months of Age

Age Common Causes Type of Vomiting Comment/Associated Features
Newborn Intestinal atresia/webs Bilious, depending on level of May occur at level of esophagus,
lesion duodenum, jejunum
Meconium ileus Bilious Strongly associated with cystic
fibrosis; genetic testing
suggested
Hirschsprung disease Bilious or nonbilious History of non-passage of stools
in nursery suggestive; suction
rectal biopsy may demonstrate
lack of intestinal ganglion
cells
Necrotizing Bilious or nonbilious Plain films of abdomen may
enterocolitis reveal intestinal pneumatoses
Inborn errors of Bilious or nonbilious May have acidosis or
metabolism hypoglycemia
0 to 3 months Pyloric stenosis Nonbilious Hypochloremic metabolic
alkalosis
Malrotation with Bilious Abdominal distention may be
midgut volvulus present; plain radiographs may
show air-fluid levels and
paucity of distal bowel gas;
emergent surgical consultation
necessary
Inborn errors of Bilious or nonbilious Newborn metabolic screen may
metabolism be abnormal; acidosis or
hypoglycemia may be present
Milk/soy protein allergy Bilious or nonbilious; may History of extreme fussiness may
have gross or occult blood be present; fecal occult blood
testing of stools may be
positive
Gastroesophageal Nonbilious; may have gross Emesis usually within 30 minutes
reflux or occult blood of feeding; symptoms worse in
supine flat position
Child abuse Nonbilious Anterior fontanelle fullness may
be present; central nervous
system (CNS) imaging studies
may reveal acute or subacute
bleeding
3 to 12 Gastroenteritis Nonbilious initially; may Stool studies may help establish
months progress to bilious offending pathogen
Intussusception Bilious Abdomen distention may be
present; plain radiographs may
show air-fluid levels and
paucity of distal bowel gas;
stools may be grossly bloody
with “currant jelly”
appearance; emergent surgical
consultation indicated; may be
reduced by contrast enema
Child abuse Nonbilious Anterior fontanelle fullness may
be present; CNS imaging
studies may reveal acute or
subacute bleeding
Intracranial mass lesion Nonbilious Anterior fontanelle fullness may
be present; CNS imaging
studies diagnostic

Figure 1. “Double bubble” sign on plain radiograph, which

represents air in the stomach and proximal duodenum and
indicates duodenal atresia.
erance, and IHPS are discussed in greater detail in this

section. Intussusception is another important cause of
vomiting in the young infant that is discussed in the next
section because it also may present beyond infancy. The
management of acute gastroenteritis is discussed in the
section on management.
Figure 3. Failure of contrast to pass beyond the second
portion of the duodenum, which is characteristic of malrota-
Gastroesophageal Reflux tion with midgut volvulus.
GER is the most common cause of recurrent nonbilious
emesis in infancy. It involves the retrograde movement of
relaxations of the LES that are not precipitated by a
gastric contents into the esophagus as a result of an
swallow, allowing gastric contents to move freely back
abnormally functioning lower esophageal sphincter
into the esophagus from an area of higher to lower
(LES). Under normal circumstances, the LES relaxes
pressure. In young infants, such relaxation often results
after swallowing to allow passage of ingested food into
from developmental immaturity of the LES, which may
the stomach. Patients who have GER have transient
improve over time. Infants who have GER present with
recurrent postprandial regurgitation of ingested food or
milk, most often within 30 minutes of a feeding. Affected
children may appear irritable during or after feedings,
and stereotypic opisthotonic movements with extension
and stiffening of arms and legs and extension of the head
(Sandifer syndrome) occasionally may be observed. In-
fants who have severe GER can have recurrent microaspi-
ration into their lungs, resulting in chronic wheezing,
respiratory symptoms, and even failure to thrive.
Infants who have the classic history of recurrent eme-
sis but who are thriving and have normal physical exam-
ination findings do not need specific treatment. Thick-
ening the formula or human milk by adding cereal may
help reduce vomiting in such infants, but elevating the
head in the supine position has no proven beneficial
Figure 2. Dilated loops of small bowel with air-fluid levels, effect. (2) Infants who are irritable during feedings and
indicative of jejunoileal atresia. those who have respiratory or growth problems may

need pharmacologic intervention. Acid blockade with those who are firstborn, are affected approximately four
histamine2 receptor antagonists or proton-pump inhibi- times as often as females. The incidence is approximately
tors may help lessen the burning sensation caused by the 3 per 1,000 live births. The exact cause of pyloric stenosis
gastric refluxant. Prokinetic agents such as metoclopra- remains unclear. The relaxation mechanism of the pyloric
mide and erythromycin may help decrease the physical smooth muscle depends on nonadrenergic noncholin-
process of GER by targeting the LES. ergic inhibitory innervation, mediated by vasoactive in-
A Cochrane meta-analysis reviewing seven random- testinal peptide and nitric oxide (NO). Deficiencies in
ized control trials showed that metoclopramide was su- neuropeptidergic innervation and NO have been impli-
perior to placebo in reducing daily symptoms of GER. cated in cases of pyloric stenosis, but neither has been
(2) However, its use must be weighed against the poten- substantiated as etiologic. Very early exposure to eryth-
tial adverse effects of extrapyramidal symptoms, head- romycin (within the first 2 weeks after birth) also has
ache, and drowsiness. Recent studies have suggested that been associated with an eightfold increased risk of pyloric
baclofen, a GABA receptor agonist, may lessen the num- stenosis. (5) It is hypothesized that erythromycin inter-
ber of transient LES relaxations via vagal-mediated acts with intestinal motilin receptors, causing strong
mechanisms and, thus, improve the pathophysiologic gastric and pyloric contractions and subsequent pyloric
process associated with GER. (3) Additional investiga- muscle hypertrophy.
tion into this agent’s overall efficacy for the treatment of Pyloric stenosis usually is diagnosed by a typical his-
GER is necessary. tory and physical findings. Inspection of the abdomen
shortly after an infant feeding may reveal a peristaltic
Dietary Protein Intolerance wave because the stomach muscles contract in an attempt
Dietary protein intolerance is a non-immunoglobulin to pass ingested milk past the pylorus. A palpable “olive”
E-mediated type of food hypersensitivity that typically in the mid-epigastric region represents the hypertrophic
presents in infants in the first postnatal year, shortly after pyloric muscle and strongly supports the diagnosis of
exposure to the offending allergen. Commonly impli- pyloric stenosis. Repeated episodes of vomiting of the
cated proteins include cow milk protein, soy protein, and gastric contents due to pyloric stenosis may result in
egg protein. Among the clinical symptoms are irritability, characteristic electrolyte abnormalities, although serum
feeding intolerance, recurrent vomiting and diarrhea, electrolyte values may be normal if the patient is diag-
and in severe cases, failure to thrive. Occasionally, pa- nosed in the early stages.
tients may present with Heiner syndrome, manifesting as The classic electrolyte abnormality is a hypochloremic
pulmonary hemosiderosis (due to recurrent microhem- hypokalemic metabolic alkalosis. Normal acid produc-
orrhages into the lungs), iron deficiency anemia, and tion in the stomach is accompanied by the release of
failure to thrive. Examination of stools in patients who bicarbonate ions into the blood as a result of the action of
have protein intolerance may reveal occult blood, with carbonic anhydrase. Because of the loss of the hydrogen
polymorphonuclear cells, lymphocytes, and eosinophils. ions, this bicarbonate is unbuffered, resulting in an en-
Stool-reducing substances may be positive due to carbo- suing metabolic alkalosis. Under normal conditions, the
hydrate malabsorption. Intestinal biopsies may reveal excess bicarbonate is excreted in the urine. However,
flattened villi and colitis with infiltration of lymphocytes, affected infants also lose significant amounts of fluid in
eosinophils, and mast cells. addition to the electrolytes. The subsequent volume
Treatment of dietary protein intolerance involves re- contraction triggers a renal response of enhanced proxi-
moval of the allergen from the diet. In the case of cow mal tubular reabsorption of bicarbonate and activation of
milk protein allergy, 80% of patients respond to hydro- the renin-angiotensin-aldosterone mechanisms. In addi-
lyzed casein formula; the remaining 20% require tion, the lack of chloride ion in the proximal tubule
L-amino acid-based formulas or intravenous nutrition. results in increased local production and reabsorption of
(4) Once elimination has occurred, symptoms usually bicarbonate, thus worsening the existing metabolic alka-
resolve in 3 to 10 days. The dietary protein intolerance losis. Under the influence of high concentrations of
typically subsides by 18 to 24 months of age. (4) aldosterone, the distal tubule excretes large amounts of
potassium and hydrogen ions in exchange of sodium.
Infantile Hypertrophic Pyloric Stenosis Lack of hydrogen ions results in enhanced excretion of
Infants who have pyloric stenosis typically present to potassium, leading to significant hypokalemia.
medical attention with persistent projectile nonbilious When the diagnosis of pyloric stenosis is being con-
emesis between 2 and 6 weeks of age. Males, especially sidered, ultrasonography of the pyloric muscle can con-

of age. Intussusception is the telescoping of one portion

of the bowel into its distal segment. Most commonly, the
terminal ileum invaginates into the cecum, often as a
result of lymphatic hypertrophy in the Peyer patches
from a recent viral infection. A history of intermittent
episodes of severe and crampy abdominal pain with bil-
ious emesis is classic. Parents often report that their child
is lethargic in between episodes of pain and may describe
blood-tinged, “currant jelly” stools. Physical examina-
tion may reveal intestinal obstruction with a sausage-
shape mass palpable in the right lower quadrant. Rapid
consultation with a pediatric surgeon is warranted. Con-
Figure 4. Thickened and lengthened pyloric muscle that is trast or air enemas can be diagnostic, with the contrast
characteristic of pyloric stenosis. outlining the lead portion of the intussusception, giving
the typical “coiled spring” appearance (Fig. 5). In addi-
firm the clinical suspicion, with sensitivity rates ranging tion, the hydrostatic pressure from the contrast enema
from 85% to 100%. (6) Pyloric muscle thickness of 4 mm may reduce telescoping of the intestine. Surgical reduc-
or more and muscle length of 14 mm or more are tion of the intussusception is indicated when the contrast
diagnostic of pyloric stenosis (Fig. 4). If ultrasono- enema is not successful.
graphic examination findings are normal, an upper GI
radiographic series can be performed. The radiographic Cyclic Vomiting Syndrome
series has a slightly higher sensitivity for pyloric stenosis Cyclic vomiting syndrome (CVS) is characterized by
(89% to 100%) and can aid in the diagnosis of other stereotypic recurrent episodes of nausea and vomiting
causes of progressive emesis in this age group, such as without an identifiable organic cause. It is an idiopathic
antral web and other structural abnormalities. Surgical disorder that usually begins in early childhood; relatively
pyloromyotomy is the definitive treatment of pyloric little is known about its pathogenesis or cause. The
stenosis and is being performed laparoscopically at many diagnosis is based on several characteristic features:
centers. 1) three or more episodes of recurrent vomiting, 2) in-
tervals of normal health between episodes, 3) episodes
Vomiting in Older Children that are stereotypic with regard to symptom onset and
Vomiting occurs most commonly in older children in the duration, and 4) lack of laboratory or radiographic evi-
setting of an acute gastroenteritis accompanied by fever dence to support an alternative diagnosis. Vomiting ep-
and diarrhea. Vomiting also can be a nonspecific mani- isodes are of rapid onset and persist for hours to days,
festation of a systemic illness, although much less com- separated by symptom-free intervals that can range from
monly than in the young infant. Both viral and bacterial weeks to years. Treatment is supportive, focused on fluid
meningitis can present with vomiting, usually accompa- management in cases where dehydration and electrolyte
nied by complaints of headache, fever, and neck stiffness.
Elevation of intracranial pressure from entities such as a
brain tumor or an intracranial hemorrhage also may
present with a chief complaint of vomiting in association
with a severe, progressive headache. Vomiting in such
patients often occurs shortly after waking in the morning
because of a gradual rise in intracranial pressure as the
child sleeps in the supine position. Inadvertent toxic
ingestions also should be considered, especially in tod-
dlers.
Intussusception
Acquired bowel obstructions such as intussusception
may present in the older infant and young child, with the Figure 5. Contrast outlining the lead portion of the intussus-
peak incidence occurring between 3 months and 3 years ception, giving the typical “coiled spring” appearance.

imbalance occur. Amitriptyline and propranolol have Superior Mesenteric Artery Syndrome
been described as effective for prophylactic therapy (an- Superior mesenteric artery (SMA) syndrome, otherwise
tiemetics may be of benefit during an acute episode). known as Wilkie syndrome or cast syndrome, is a func-
tional upper intestinal obstructive condition. Normally,
the SMA forms a 45-degree angle, with the abdominal
Abdominal Migraine aorta at its origin and the third portion of the duodenum
Abdominal migraines involve episodic attacks of epigas- crossing between the two structures. When the angle
tric or periumbilical abdominal pain and are believed to between the SMA and the aorta is narrowed to less than
share pathophysiologic mechanisms with CVS. Abdom- 25 degrees, the duodenum may become entrapped and
inal migraines are more common in females than in compressed. This condition most commonly is described
males, with a ratio of 3:2, and the onset is primarily in patients who have experienced rapid weight loss, im-
between 7 and 12 years. A family history of migraine mobilization in a body cast, or surgical correction of
headaches may be present. Episodes of abdominal pain spinal deformities.
are acute in onset and last for 1 hour or more. The pain is SMA syndrome typically presents with epigastric ab-
so intense that it interferes with the performance of dominal pain, early satiety, nausea, and bilious vomiting.
normal activities and is associated with anorexia, nausea, Patients experience worsening pain in the supine posi-
vomiting, headache, photophobia, and pallor. Much like tion, which may be relieved in the prone or knee-chest
those who have CVS, patients who have abdominal position. Diagnosis usually is confirmed by upper GI
migraines report intervals of completely normal health radiographic series (Fig. 6) or computed tomography
between the episodes of pain. Diagnostic evaluation scan (Fig. 7) with failure of contrast to pass beyond the
looking for alternative organic conditions yields negative third portion of the duodenum. Conservative initial
results. The diagnosis of abdominal migraine is sup- management of SMA syndrome focuses on gastric de-
ported by a favorable response to medications used for compression, followed by the establishment of adequate
treatment of migraine headaches. Patients should be nutrition and proper positioning after meals. Placement
advised about trigger avoidance, specifically caffeine- of an enteral feeding tube distal to the obstruction or
containing foods, altered sleep patterns, prolonged fast- parenteral nutrition may be needed in severe cases. Sur-
ing, emotional stress, and exposure to flickering lights. gical correction with a duodenojejunostomy is a last
resort.
Rumination
Rumination is the repeated and painless regurgitation of
ingested food into the mouth beginning soon after food
intake. The food is re-chewed and swallowed or spit out.
Symptoms do not occur during sleep and do not respond
to the standard treatment of GER. To qualify for the
diagnosis, symptoms must be present for longer than
8 weeks. Rumination is not associated with retching and
often is viewed as a behavioral entity, typically seen in
mentally retarded children, neonates during prolonged
hospitalization, and children and infants who have GER.
Rumination also has been described in cases of child
neglect and in older children and adolescents who have
bulimia or are depressed. Most commonly, rumination is
seen among female adolescents or male infants. One
third of affected individuals have underlying psycholog-
ical disturbances. The management of rumination in-
volves a multidisciplinary approach, with a primary focus
on behavioral therapy and biofeedback. Occasionally, Figure 6. Severely dilated stomach and proximal duodenum
tricyclic antidepressants and nutritional support may be indicative of high obstruction consistent with superior mes-
necessary. enteric artery syndrome.

receptor antagonists at the chemoreceptor trigger zone.

Such drugs rarely are used in pediatric patients because of
their extrapyramidal and sedative adverse effects. Antihis-
tamines such as diphenhydramine, hydroxyzine, and di-
menhydrinate also may help alleviate nausea and vomit-
ing but have a sedative effect that makes clinical re-
evaluation difficult. A newer class of antiemetics is the
5HT3-receptor antagonists, ondansetron and granis-
etron. The 5HT3 blockade occurs both at the enteric
level and at the chemoreceptor trigger zone. These
drugs, unlike the phenothiazines and antihistamines, do
not have central nervous system adverse effects, making
them more attractive options. The 5HT3-receptor an-
tagonists have been approved for the management of
chemotherapy-induced nausea and vomiting and for
Figure 7. Computed tomography scan of the abdomen reveals pregnancy-associated and postoperative vomiting in
dilated stomach and duodenum with air-fluid levels. The adults. For children, however, there is no substantive
duodenum tapers abruptly (arrow) as it crosses the midline scientific evidence supporting their efficacy in treating
between the aorta and the superior mesenteric artery.
acute gastroenteritis. Therefore, these agents have not
been endorsed officially for routine use.
General Principles in the Management of
Vomiting
Therapy to alleviate vomiting should be directed at the Conclusion
specific cause, when possible. Gastrointestinal obstruc- Vomiting is a nonspecific symptom that may accompany
tions should be corrected, as deemed appropriate by the a wide variety of GI and extraintestinal disorders. Serious
pediatric surgery team. Management of nonsurgical extraintestinal causes of vomiting include brain tumor
causes of vomiting include steps to correct fluid and and meningitis; congenital or acquired intestinal ob-
electrolyte imbalances that result from prolonged or structive syndromes are the most serious intestinal
excessive vomiting and to identify and treat the underly- causes. Associated fluid and electrolyte imbalances always
ing disorder causing the symptom. The 2003 Centers for must be considered when assessing a child who has a
Disease Control and Prevention practice guidelines for history of vomiting. Conditions such as mild GER may
the management of acute gastroenteritis in children, only necessitate reassurance, but symptoms of bilious
endorsed by the American Academy of Pediatrics, rec- vomiting should prompt immediate referral to a pediatric
ommend oral rehydration therapy (ORT) in cases of surgeon. Results of the history and physical examination,
mild-to-moderate dehydration from acute gastroenteri- keeping in mind the nature of the vomiting and age of
tis. (7) Using an appropriate glucose-electrolyte solu- the child, may help the clinician determine the likely
tion, 50 to 100 mL/kg of fluid should be administered cause and the need for emergent treatment.
to the child over the course of 4 hours, along with
replacement of continuing losses from stool and emesis. ACKNOWLEDGMENT. The authors would like to ex-
This is most effective when the ORT is administered in press their gratitude to Dr Dvorah Balsam for the images
small, 5-mL increments every 1 to 2 minutes. In cases of and the descriptions of the findings.
severe dehydration, ileus, or persistent vomiting despite
adequate attempts at ORT, parenteral fluids must be
administered. References
Although the previously cited guidelines do not rec- 1. Godbole P, Stringer MD. Bilious vomiting in the newborn: how
ommend the routine use of antiemetic drugs in the often is it pathologic? J Ped Surg. 2002;37:909 –911
management of patients who have acute gastroenteritis, 2. Craig WR, Hanlon-Dearman A, Sinclair C, Taback S, Moffatt
unique situations may warrant their use. If the cause of M. Metoclopramide, thickened feedings, and positioning for
gastro-oesophageal reflux in children under two years. Cochrane
the vomiting is unclear, antiemetics are contraindicated. Database Syst Rev. 2004;4:CD003502
Phenothiazines such as prochlorperazine, promethazine, 3. Di Lorenzo C. Gastroesophageal reflux: not a time to “relax.”
and chlorpromazine are antiemetics that act as D2- J Pediatr. 2006;149:436 – 438

4. Scurlock AM, Lee LA, Burks AW. Food allergy in children. Haghighat M, Rafie SM, Dehghani SM, Fallahi GH, Nejabat M.
Immunol Allergy Clin North Am. 2005;25:369 –388 Cyclic vomiting syndrome in children: experience with 181
5. Cooper WO, Griffin MR, Arbogast P, Hickson GB, Gautam S, Ray cases from southern Iran. World J Gastroenterol. 2007;13:
WA. Very early exposure to erythromycin and infantile hypertrophic 1833–1836
pyloric stenosis. Arch Pediatr Adolesc Med. 2002;156:647– 650 Hulka F, Campbell TJ, Campbell JR, Harrison MW. Evolution in
6. Mandell GA, Wolfson PJ, Adkins ES, et al. Cost-effective imaging the recognition of infantile hypertrophic pyloric stenosis. Pedi-
approach to the nonbilious vomiting infant. Pediatrics. 1999;103: atrics. 1997;100:e9
1198 –1202 Kapfer SA, Rappold JF. Intestinal malrotation–not just the
7. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastro- pediatric surgeon’s problem. J Am Coll Surg. 2004;199:
enteritis among children: oral hydration maintenance and nutritional
628 – 635
therapy. MMWR Morbid Mortal Wkly Rep. 2003;52(RR16):1–16
Kimura K, Loaning-Baucke V. Bilious vomiting in the newborn:
rapid diagnosis of intestinal obstruction. Am Fam Physician.
Suggested Reading 2000;61:2791–2798
Biank V, Werlin S. Superior mesenteric artery syndrome in children: Rasquin A, DiLorenzo C, Forbes D, et al. Childhood functional
a 20 year experience. J Pediatr Gastroenterol Nutr. 2006;42: gastrointestinal disorders: child/adolescent. Gastroenterology.
522–525 2006;130:1527–1537
PIR Quiz
Quiz also available online at www.pedsinreview.org.
Match the clinical finding with the most likely condition. Each answer may be used once, more than once, or
not at all.
1. Flattened villi and colitis on biopsy.
2. Uncoordinated esophageal relaxation.
3. Hypochloremic hypokalemic metabolic alkalosis.
4. Recurrent microaspiration.
5. “Coiled spring” appearance on radiography.
A. Abdominal migraine.
B. Gastroesophageal reflux.
C. Intussusception.
D. Protein intolerance.
E. Pyloric stenosis.

Article complementary medicine
Complementary, Holistic, and

Integrative Medicine: Therapies for
Acute Otitis Media
Cecilia Bukutu, PhD,* Introduction
Janjeevan Deol,* Sunita Acute otitis media (AOM) is diagnosed frequently in early childhood; its peak incidence is
Vohra, MD, FRCPC, MSc* between 6 and 15 months of age. (1) Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis are the leading bacterial causes. Eighty percent of AOM cases
resolve without treatment within 3 days. (2)(3) This high rate of spontaneous resolution
Author Disclosure along with variations in diagnostic criteria complicate studies of otitis media. Most cases of
AOM are treated with antibiotics and pain relievers, but antibiotics may contribute to
Dr Bukutu and Mr
antimicrobial resistance or produce adverse effects (AEs) such as diarrhea. (4) These
Deol have disclosed
concerns, in part, have led some parents to turn to the use of complementary and
no financial alternative medicine (CAM) to treat childhood AOM. This review of published scientific
relationships relevant literature examines some commonly used CAM therapies in the prevention and treatment
to this article. Dr of childhood AOM.
Vohra has disclosed
receiving salary
Natural Health Products
Naturopathic Herbal Ear Drops (NHEDs)
support from the
A Cochrane systematic review conducted in 2004 (4) assessed the effectiveness of NHEDs
Alberta Heritage in the management of ear pain associated with AOM in two randomized, controlled trials
Foundation for (RCTs) (Table 1). The first study compared an NHED comprised of Calendula flores
Medical Research (marigold), garlic (Allium sativum), mullein (Verbascum thapsus), and St. John’s wort
Population Health (Hypericum perfoliatum) in olive oil with anesthetic eardrops. (5) The second study
compared NHED (garlic, mullein, marigold, St John’s wort, lavender, and vitamin E in
and Canadian
olive oil) to anesthetic eardrops with and without antibiotics. (6) Findings from these trials
Institutes of Health
point to NHEDs being modestly therapeutic for pain associated with AOM compared with
Research. This review anesthetic eardrops. However, the trials have some methodologic problems: lack of
was funded in part by allocation concealment, power calculation, and intention-to-treat analysis. Two children
PasseportSanté.net. dropped out of the first study because of the odor of NHED; no other AEs were
This commentary does documented. (5) The evidence regarding safety and efficacy of NHEDs seems promising.
contain a discussion
Other Natural Health Products
of unapproved/
An Israeli double-blind RCT in which 430 children ages 1 to 5 years ingested either
investigative use of a 5 mg/mL or 7.5 mg/mL of a mixture containing echinacea, propolis, and vitamin C or
commercial product/ placebo twice daily for 12 weeks found the mixture to be effective in preventing AOM. (7)
device. Compared with placebo, the mixture reduced the number of AOM episodes per child by
68% (P⬍0.001). AEs reported in nine children, including seven from the mixture group
and two from the placebo group (P⫽0.54), were mild gastrointestinal and palatability
symptoms.
Xylitol
Used as a sweetener in chewing gums and other dietetic products, xylitol is a natural sugar
found in strawberries, raspberries, rowanberries, and plums. In addition to inhibiting the
growth of S mutans, which is responsible for dental cavities, it also prevents S pneumoniae
from growing or attaching to nasopharyngeal cells. (8)
Four double-blind RCTs (9)(10)(11)(12) have examined the effectiveness of xylitol in
*Complementary and Alternative Research and Education (CARE) Program, Department of Pediatrics, University of Alberta,
Edmonton, Alberta, Canada.
NOTE: The agents discussed in this series are designated as dietary supplements rather than drugs. Although dietary
supplements are regulated by the United States Food and Drug Administration (FDA), their manufacturers may make claims
with little evidence and need not prove safety prior to marketing. The burden is on the FDA to monitor safety after the
product is on the market. Readers are referred to the 1994 Dietary Supplement Health and Education Act (www.cfsan.fda.gov/
⬃dms/dietsupp.html).

complementary medicine otitis media
Clinical Trials of Naturopathic Ear Drops for Acute Otitis Media

Table 1.
in Children
Citation Study Type Population Intervention Outcomes Results Comments
Sarrell et al. Double-blind 103 children Group A: Naturopathic Severity and duration NHED reduced pain Children older than
(2001) RCT ages 6 to drops (Allium of pain as effectively as the age group
(5) 18 y who sativum, Verbascum Two visual (linear anesthetic ear in which peak
had thapsus, Calendula and color) analog drops AOM incidence
otalgia flores, Hypericum scales used Pain score improved occurs (6 to
associated perforatum in olive Ear pain assessed throughout the 15 mo)
with AOM oil) prior to treatment course of the 7 dropouts (2 did
(Israel) Group B: Anesthetic and at 15 and study period not like odor of
ear drops 30 min after (Pⴝ0.007) the NHED, 5 for
(amethocaine, treatment noncompliance)
phenazone, Randomization
glycerine) method not
In both groups, drops described
instilled 3 times
daily for 3 days
At start, all children
given a single dose
of acetaminophen
(15 mg/kg)
Sarrell et al. Double-blind Ambulatory Children randomized As in Sarrell, 2001 After 3 days, rate Children older than
(2003) RCT clinic, 171 into 1 of 4 of pain reduction: the age group
(6) children treatments and Group Aⴝ95.9%, in which peak
(5 to 18 y) received eardrops Group Bⴝ90.9%, AOM incidence
who had 3 times daily for Group Cⴝ84.0%, occurs (6 to
otalgia 3 days Group Dⴝ77.8% 15 mo); thus,
associated Group A: NHED alone Pain was mostly likely greater
with AOM (Allium sativum, (80%) self- chance of
(Israel) Verbascum thapsus, limited and spontaneous
Calendula flores, explained by the recovery
Hypericum passage of time
perfoliatum,
lavender, and
vitamin E in olive
oil)
Group B: NHED with
oral amoxicillin
(antibiotic)
Group C: Anesthetic
eardrops alone
Group D: Anesthetic
eardrops with oral
amoxicillin
(antibiotic)
AOM⫽acute otitis media, NHED⫽ naturopathic herbal ear drops. RCT⫽randomized, controlled trial.
preventing AOM in children attending child care centers who took xylitol dropped out due to abdominal discom-
in Finland (Table 2). In two RCTs, xylitol reduced the fort compared with five who took placebo.
risk of developing AOM by 41% and 40%. (9)(10) In A third RCT using the same dosing schedule, but in
these studies, healthy children ingested 8.4 to 10 g of which xylitol (as a mixture, chewing gum, or lozenge)
xylitol divided into five doses daily for 2 or 3 months. was administered to children who had acute respiratory
Two children who took xylitol dropped out due to infection, found xylitol to be ineffective in preventing
diarrhea in the earlier trial; in the later trial, 16 children AOM. Seven children who took xylitol dropped out

Table 2. Summary of Xylitol Intervention Trials

Citation Study Type Population Intervention Outcomes Results Comments
Uhari et al. Double-blind 306 healthy Group A: Xylitol chewing Reduction in AOM Xylitol reduced 2 children dropped
(1996) RCT children gum (8.4 g/d) episodes occurrence of out due to
(9) (mean age, Group B: Sucrose AOM by 41% diarrhea
4.9 y) at chewing gum (95% CI: (Group A)
child care Dosages taken 5 times 4.6% to
centers daily for 2 months 55.4%)
Uhari et al. Double-blind 857 healthy Group A: Xylitol chewing Reduction in AOM Xylitol reduced 16 dropouts due
(1998) RCT children at gum (between 8.4 g/d episodes occurrence of to abdominal
(10) child care and 10 g/d) AOM by 40% discomfort in
centers Group B: Xylitol syrup (95% CI: 10% Groups A to C
(between 8.4 g/d and to 71.1%) versus 5 in
10 g/d) Group D
Group C: Xylitol lozenges
(between 8.4 g/d and
10 g/d)
Group D: Placebo
Doses taken 5 times
daily for 3 months
Tapiainen Double-blind 1,277 children Group A: Xylitol mixture Occurrence of AOM occurrence: Dropouts: Disliked
et al. RCT (ages 10 Group B: Control mixture AOM Group Aⴝ intervention
(2002) mo to 7 y) Group C: Xylitol chewing 20.5% versus product: group
(11) who had gum Group Bⴝ Eⴝ10, group
acute Group D: Xylitol control 20.4% (NS) Cⴝ1
respiratory chewing gum Groups C Abdominal
infection Group E: Xylitol lozenges (14.1%) and D discomfort all
Doses taken 5 times (11%) versus xylitol
daily until symptom Group E groupsⴝ7,
resolution or up to (15.5%) (NS) controlⴝ2
3 wk Xylitol
ineffective
Hautalahti Double- 663 healthy Group A: Xylitol chewing Number of AOM 156 AOM Dropouts: controlⴝ
et al. blind RCT children gum (9.6 g/d) episodes episodes in 38 (11%)
(2007) (ages 7 mo Group B: Control xylitol group versus 58
(12) to 7 y) (0.5 g/d) versus 142 in (17%) in the
Doses taken 3 times control (NS) xylitol group
daily for 3 mo Xylitol (Pⴝ0.028)
ineffective
AOM⫽acute otitis media, CI⫽confidence interval, NHED⫽naturopathic herbal ear drops, NS⫽not significant, RCT⫽randomized, controlled trial.
versus two who took the control. Furthermore, 11 chil- common reason for dropping out was refusal to take the
dren dropped out due to disliking the intervention prod- preparation.
uct (10 from the xylitol lozenge group and one from the Xylitol has few reported AEs. In large doses, it may
xylitol chewing gum group). cause abdominal pain and loose stools. (9) A study
Taking xylitol five times per day to prevent AOM may examining various doses in 13 children (ages 7 to 16 y)
be impractical for children and parents. The fourth trial found flatulence increased at a 45-g/d dose, but no
of 663 children ages 7 months to 7 years assessed diarrhea occurred at doses less than 65 g/d. (13) A tol-
whether administering xylitol (chewing gum or a oral erability study of 120 children (ages 6 to 36 mo) found
mixture) less frequently (three times daily) would reduce oral xylitol solution doses of 5 g taken three times a day
the occurrence of AOM. (12) Xylitol (9.6 g/d divided and 7.5 g taken once daily to be well tolerated. (14) The
into three doses) was found to have no preventive effect. effectiveness of this dosing schedule has yet to be evalu-
Thirty-eight children (11%) dropped out in the control ated through an RCT. The occurrence of AEs was not
group and 58 (17%) in the xylitol group (P⫽0.028). The significantly different between groups and included ex-

cessive gas and diarrhea. Although the results for xylitol During this time, children who had no AOM recurrences
effectiveness are mixed, its use is safe except in huge within 1 month (n⫽22) received 25 mg/kg of phen-
doses. Moreover, xylitol (taken in a mixture or chewing oxymethylpenicillin and placebo nasal spray. More chil-
gum) may provide dual protection for children by help- dren (42%) given probiotic streptococcal nasal spray had
ing to prevent AOM as well as dental caries. (8)(9) no AOM recurrences and normal tympanic membranes
than children given placebo (22%, P⫽0.02). Of 45 AEs
reported, 22 were in the streptococcal group and 25 were
Probiotics in the placebo group. Details of the AEs were not pro-
Probiotics are believed to reduce upper respiratory tract vided.
colonization with pathogenic bacteria by stimulating Probiotics have a favorable safety profile in healthy
antibody production and enhancing the phagocytic ac- individuals. In immunocompromised adults, there have
tivity of blood leukocytes. (15) Findings from three been reports of pneumonia, bacteremia/septicemia, and
double-blind RCTs are presented. meningitis. LGG has been associated with bacteremia in
Hatakka and colleagues (16) assessed the long-term two immunocompromised pediatric patients. (18) Al-
effectiveness of oral probiotics for AOM prevention in though favorable findings of the effectiveness of probi-
571 children (ages 1 to 6 y) from 18 Finnish child care otics exist, additional investigations are needed before
centers. Children drank milk formula either with conclusive recommendations for their use to prevent
(n⫽282) or without (n⫽289) Lactobacillus rhamnosus AOM can be made.
GG (LGG) three times daily, 5 days a week for 7 months.
On average, children from both groups drank 260 mL/d
of milk. Over the study period, children who drank milk Cod Liver Oil
with LGG were absent from child care for fewer days (4.9 Cod liver oil is an excellent source of omega-3 fatty acids
versus 5.8 days, P⫽0.03). They also had fewer antibiotic and vitamins A and D. Linday and colleagues (19) found
treatments and fewer episodes of AOM. This result was that children who have recurrent AOM have lower red
not statistically significant when adjusted for age. blood cell concentrations of the omega-3 fatty acid eico-
In a later study, Hatakka and associates (17) assessed sapentaenoic acid (EPA), vitamin A, and selenium than
the effectiveness of a probiotic combination (LGG and L those who do not have recurring AOM. These micronu-
rhamnosis strain C705, Bifidobacterium breve 99, and trients are believed to have important effects on immune
Propionibacterium freudenreichii JS) for reducing the function. The authors conducted a small open-label pilot
occurrence and duration of AOM in 306 AOM-prone study in which eight children (0.8 to 4.4 y) took 1 tsp of
children (ages 10 mo to 6 y). Children consumed either lemon-flavored cod liver oil (containing EPA and vita-
one probiotic capsule (n⫽155) or placebo (n⫽154) daily min A) plus half a tablet of multivitamin supplement
for 24 weeks. Probiotic treatment did not reduce the containing selenium for up to 7 months. During this
occurrence or recurrence of AOM episodes, nor did it period, children received antibiotics for OM for 12%
affect the carriage of S pneumoniae or H influenzae. fewer days than before taking part in the study (P⬍0.05).
However, the intervention did increase the prevalence of One child who could not tolerate the taste of cod liver oil
M catarrhalis (odds ratio⫽1.79, 95% confidence inter- discontinued participation. Concerns regarding the pos-
val, 1.06 to 3.00, P⫽0.028). Each group had 20 drop- sible AEs of long-term consumption of cod liver oil are
outs due to sickness, noncompliance, personal reasons, related to the dangers of polychlorinated biphenyls and
and “not known.” One AE was reported in the probiotics dioxin residues found in fish oil that have been implicated
group (no additional description given). in a range of health conditions. Although this small
A 3-month Swedish study investigated the efficacy of open-label study suggests that cod liver oil may be ben-
using a probiotic nasal spray of streptococci (S sanguis, eficial, definitive recommendations are premature.
S mitis, and S oralis in equal portions) for preventing the
recurrence of AOM in 108 children (ages 6 mo to 6 y).
(15) Children who had an AOM recurrence within Homeopathy
the previous month (n⫽82) received 20 mg/kg of Anecdotal evidence suggests that homeopathy may be
amoxicillin/clavulanic acid twice daily for 10 days fol- beneficial for children who have AOM. Five studies
lowed by 10 days of a nasal “probiotic” spray, then (three RCTs and two observational) have evaluated the
60 days of no use, and another 10 days of the nasal spray. efficacy of homeopathy for treating AOM in children

(Table 3). Findings suggest that homeopathy results in a Given the combined high rate of spontaneous AOM
rapid reduction in symptoms, a shorter duration of pain, resolution and methodologic limitations of the studies
and a reduction of both AOM recurrences and antibiotic presented (convenience sample, nonstandardized out-
use. One study also assessed the cost effectiveness of come measures, nonblinded ratings of improvement, and
homeopathy compared with that of conventional treat- lack of control groups), the effectiveness of chiropractic
ment and found homeopathy to be 14% cheaper. (23) care for AOM is not well defined. Furthermore, the
A few AEs were observed in some of the studies, but safety of pediatric spinal manipulation is not yet known.
these occurred in the control groups. One Swiss study Although rare, serious AEs, including paraplegia and
noted three cases of severe AEs in 7 years of homeo- death, have been reported. (29) Due to anatomic imma-
pathic care practice: one central perforation of a tympanic turity, young children are particularly vulnerable to in-
membrane, one cholesteatoma, and one case of mastoid-
jury from rapid rotational movement or excessive force.
itis. (23)
Due to their dilute nature, homeopathic remedies
generally are regarded as carrying little risk of harm.
Aggravation of symptoms, in which patients’ current Osteopathy
symptoms worsened for a few hours after taking homeo- Two studies (one cohort, one RCT) have assessed the
pathic medicine, have been reported in 10% to 20% of efficacy of osteopathic manipulation techniques (OMTs)
patients. (25) Although findings for homeopathy are in treating AOM. One RCT evaluated its impact in
promising, more rigorously designed studies (large, children (6 mo to 4 y) on frequency of AOM episodes,
blinded, randomized, and controlled) are needed to subsequent ear surgery, hearing loss, behavior, antibiotic
substantiate the results. It also would be useful to com- use, and parent opinion. (30) Children received either
pare patients treated homeopathically with those treated “gentle” OMT (n⫽32) or standard pediatric care (ie,
with other treatments (eg, herbal ear drops, topical an- antibiotics) (n⫽25). Treatment was administered at nine
esthetics, systemic antibiotics) in terms of their symp- study visits: 3 weekly, 3 biweekly, and 3 monthly, with
toms, AEs, costs, and parental satisfaction and interest in treatment duration between 15 and 25 minutes. Patients
using such treatments in the future. receiving OMT had fewer episodes of AOM, with a
mean difference between groups of ⫺0.14 (P⫽0.04) per
Chiropractic month. Only one ear surgery was required in patients
Three cohort studies (ie, no control group) in the United receiving OMT compared with eight in those receiving
States have examined the efficacy of chiropractic care to standard of care (P⫽0.03). No significant differences
treat AOM in children and have reported positive find- between the groups were noted in antibiotic use, hearing
ings. The first was a case series of 332 children (ages 27 d test results, parent-rated behavior, or parental satisfac-
to 5 y) who had a previous diagnosis of OM (acute and tion with treatment. The study had a high dropout rate
chronic). (26) Children who had AOM (n⫽127) and
(25%), with two primary reasons cited: loss of continuity
received an average of 4⫾1.03 adjustments attained nor-
of physician care and inconvenience of a 6-month study.
mal otoscopic and tympanographic examination findings
Positive findings also were reported in a 2006 pilot
after 6.67 (⫾1.9) and 8.35 (⫾2.88) days, respectively.
cohort study of eight children (ages 7 to 25 mo) who had
The overall AOM recurrence rate over a 6-month period
recurrent AOM. (31) The study consisted of a 1-year
was 11.02%. The second study, a retrospective cohort
design, assessed the impact of care from one chiropractor follow-up period of children who received weekly OMTs
on 46 children (ages ⬍5 y) who had a total of 95 AOM concurrently with routine medical care (ie, antibiotics)
episodes. (27) Overall, 93% of AOM episodes improved, for 3 weeks. Although OMT was found to be beneficial
with 75% of the improvements occurring within 10 days. in preventing the occurrence of AOM in five of eight
A 2004 cohort study of 21 children (9 mo to 9 y) who children, the lack of a control group made it impossible
had severe red, bulging tympanic membranes in the to determine if OMT was responsible.
middle ear and moderate fever (average 100°F [37.8°C]) Results from small studies that have limited statistical
found that after three to six “toftness” (low force) chiro- power suggest that osteopathy might be a promising
practic adjustments over a 14-day period, tympanic adjuvant therapy in the prevention of recurrent AOM,
membranes returned to normal in 95% of children. (28) but larger clinical trials evaluating the safety and cost-
The temperature also was reported to decrease to an benefit of osteopathy are essential before conclusions
average of 98.6°F (37.0°C). about its efficacy can be made.

Table 3. Summary of Homeopathic Interventions

Citation Design Population Intervention Outcomes Results Comments
Friese et al. Open prospective 131 children Group A (nⴝ103): Duration of pain Median No randomization
(1997) observational with AOM Single homeopathic and therapy, duration of (potential
(20) (age 6 mo to remedies number of therapy was selection bias),
11 y) (Aconitum recurrences significantly unequal group
(Germany) anapellus, Apis after 1 y less in sizes
mellifica, Group A AEs observed in
Belladonna, (4 d versus Group B
Capsicum, 10 d) (diarrhea,
Chamomilla, Duration of stomachaches)
Kalium pain and
bicrhomicum, number of
Lachesis, recurrences
Lycopodium, was better
Mercurious for Group
solubilis, Okoubaka, A patients
Pulsatilla, Silicea) (NS)
Group B (nⴝ28):
Conventional
therapy (nasal
drops, antibiotics,
secretolytics, and/
or antipyretics)
Harrison Nonblinded RCT 33 Children Group A: Homeo- Hearing loss, More Group A Small study,
et al. (ages 18 mo pathic treatments tympanography, patients possibility of
(1999) to 8 y) with (range, 6 to 9) antibiotic use, (76%) had randomization
(21) OM with Group B: Standard referral to normal being uncon-
effusion care of wait and specialists tympano- cealed
(OME), watch policy over gram 2 patients from
abnormal 12 mo findings Group A
tympanogram compared withdrew (no
finding, and with reason
hearing loss controls provided)
>20 dB (31%)
(United (Pⴝ0.015)
Kingdom)
Jacobs et al. Double-blind 75 children with Group A: Individual- Treatment Decrease in Definition of
(2001) RCT pilot AOM (ages 18 ized homeopathic failure after symptoms AOM
(22) study mo to 6 y) medicine (most 5 d, 2 wk, at 24 h and Small sample size
(United common being and 6 wk 64 h in
States) Pulsatillanigran, Diary symptom favor of
Chamomilla, scores homeo-
sulphur, Calcarea pathy
carbonica) (Pⴝ0.05)
Group B: Placebo
taken orally
3 times daily for
5d
Frei and Open trial 230 Children Individualized Pain reduction Improvement No control group
Thruneysen with AOM homeopathic at 6 and in 39% of
(2001) (ages 0 to medicine 12 h after patients
(23) 16 y) instillation after 6 h,
(Switzerland) another
33% after
12 h
(continued)

Table 3. Summary of Homeopathic Interventions (Continued)

Citation Design Population Intervention Outcomes Results Comments
Wustrow Open, nonran- 390 children Group A (nⴝ192): Time to recovery, Fewer children Treatment allo-
et al. domized, with AOM Homeopathic pain resolu- given cation not
(2004) controlled, (ages 1 to formula (Echinacea tion, antibiotic homeo- randomized
(24) parallel-group 10 y) purpurea, use pathic Group B: One
study (Germany) Sambucus nigra, treat- adverse drug
Sanguinaria ment com- reaction (rash)
canadensis, pared with reported
Chamomilla control
recutita); parents took
decided whether antibiotics
child was (14.4%
intervention group versus
or not 80.5%,
Group B (nⴝ193): Pⴝ0.001)
Conventional and
treatment (ie, analgesics
decongestant nose (53.2%
drops, mucolytics, versus
analgesics, and 66.8%,
antibiotics) Pⴝ0.007)
AE⫽adverse effects, AOM⫽acute otitis media, NS⫽not significant, RCT⫽randomized, controlled trial.
Conclusion use of antibiotics and subsequent bacterial resistance.

Numerous studies have evaluated the effectiveness or Cost-effectiveness and parent/child preferences need to
safety of natural health products, homeopathy, chiro- be evaluated in large, well-designed research studies be-
practic, and osteopathic care to treat pediatric AOM, but fore general recommendations can be made regarding
methodologic shortcomings preclude definitive conclu- use of these CAM therapies for children who have AOM.
sions. This review suggests that xylitol, probiotics, herbal
ear drops, and homeopathic interventions may be bene- NOTE: References for this article are published in
ficial in reducing pain duration as well as decreasing the the online edition of this month’s Pediatrics in Review.

index of suspicion
Case 1 Presentation diagnosis is made only after a proce-

A 21-month-old boy presents with dure.
5 weeks of progressive abdominal
distention and vomiting. The left
side of his abdomen would swell, par-
ticularly after meals, and then recede; Case 2 Presentation
for the last 10 days, however, his An 8-year-old boy is evaluated for
abdomen has been distended con- severe abdominal pain. Two weeks
stantly. He vomits shortly after any ago, he developed severe, sharp,
attempt to eat, and the vomitus is not right-sided lower quadrant pain
The reader is encouraged to write bilious or bloody. When not vomit-
without radiation, not associated
possible diagnoses for each case before ing, he appears comfortable. He has
with food or movement, as well as
turning to the discussion. We invite been afebrile.
readers to contribute case presentations temperature to 101.6°F (38.7°C)
Prior to this episode, he has been
and discussions. Please inquire first by and nausea, but no vomiting or an-
contacting Dr. Deepak Kamat at well, developing normally and grow-
orexia. Abdominal ultrasonography
dkamat@med.wayne.edu. ing along the 10th percentile for
height and weight. He has had no showed normal findings. His fever
recent infections or trauma and is has resolved, but he continues to
receiving no medications. have abdominal pain and nausea and
Author Disclosure
On physical examination, his tem- has lost 4 lb over the last 2 weeks.
Drs Barrett, Cho, Li, Senthilnathan,
perature is 99.0°F (37.2°C), heart Today his stools contain blood and
Poret, and Wenger and Mr Brown have mucus, but he has not had diarrhea
rate is 104 beats/min, respiratory
disclosed no financial relationships rate is 22 breaths/min, and blood or constipation. He has not traveled
relevant to these cases. This pressure is 93/58 mm Hg. He ap- recently and has not gone camping,
commentary does not contain a pears cachectic and weighs 10.4 kg ingested well water, had a chronic
discussion of an unapproved/ (5th percentile). His abdomen is illness, or had any contact with ill
investigative use of a commercial
grossly distended, dull to percussion, people recently. There is no family
and not tender. A solid, firm mass history of inflammatory bowel dis-
product/device.
encompasses the left flank, extend- ease.
ing 4 cm past midline to the right. Physical examination reveals an
The superior and inferior edges can- uncomfortable boy lying on his
not be discerned, and the liver and left side. His abdomen is soft but
Frequently Used Abbreviations spleen cannot be distinguished as diffusely tender to palpation, with
ALT: alanine aminotransferase
either separate from or part of the increased right-lower quadrant and
AST: aspartate aminotransferase
mass. suprapubic tenderness. He has vol-
BUN: blood urea nitrogen
His white blood cell count is
untary guarding, but no rebound
CBC: complete blood count
17.0⫻103/mcL (17.0⫻109/L) with
tenderness, hepatosplenomegaly,
CNS: central nervous system a normal differential count, Hgb is
perianal erythema, or perianal fis-
CSF: cerebrospinal fluid 11.3 g/dL (113 g/L), Hct is 36.1%
sures. Bowel sounds are present.
CT: computed tomography (0.361), mean corpuscular volume
His stool is guaiac-positive. The re-
ECG: electrocardiography is 76.1 fL, and platelet count is
653.0⫻103/mcL (653.0⫻109/L). mainder of his physical findings are
ED: emergency department
Results of serum chemistries and normal.
EEG: electroencephalography
hepatic function tests are normal ex- A complete blood count is nor-
ESR: erythrocyte sedimentation rate
cept for a bicarbonate concentration mal, as are results of liver function
GI: gastrointestinal
of 17.0 mEq/L (17.0 mmol/L). tests and lipase concentration. He
GU: genitourinary
C-reactive protein is elevated at has a negative stool culture and a
Hct: hematocrit
2.2 mg/dL (0.22 mg/dL). Urinaly- negative ova and parasites test. CT
Hgb: hemoglobin
MRI: sis yields normal results. scan of the abdomen and pelvis yields
magnetic resonance imaging
WBC: white blood cell An abdominal radiograph leads normal results. An additional diag-
to additional imaging, but the final nostic test reveals the diagnosis.

index of suspicion
Case 3 Presentation
Two days after jumping on her tram-
poline, a 9-year-old girl presents with
recurrent lower back and flank pain
that radiates to her upper thighs. She
underwent an appendectomy 11 days
ago after an episode of abdominal
pain that also started after jumping
on the trampoline. She recovered
well, but similar pain returned 2 days
ago and is accompanied by sleep dis-
turbance, nausea, vomiting, and
anorexia, prompting admission to a
local hospital.
At the hospital, her physical find-
ings are normal except for right Figure 1. Radiograph showing a large, homogeneous mass arising from the left side of
the abdomen, displacing the large bowel.
lower quadrant tenderness. Results
of electrolyte measurements, CBC,
liver function tests, amylase measure- revealed a 10⫻13-cm, well-defined, Differential Diagnosis
ment, and urinalysis are within nor- fluid-filled mass arising from the left The differential diagnosis for ab-
mal limits, and her appendix is re- abdomen inferior to the stomach. dominal masses in children is wide
ported to be normal on pathologic The origin of the mass was unclear and varied. Possibilities include GI
examination. Persistence of the pain from the CT scan, and the patient tract abnormalities such as hepato-
has led to transfer to a tertiary care underwent exploratory laparotomy, splenomegaly, volvulus, constipation,
hospital. which revealed a giant pancreatic intussusception, pancreatic pseudo-
The girl has had no dysuria, uri- pseudocyst in the tail of the pancreas. cyst, and duplication cysts. Fluid col-
nary frequency, hematochezia, or Cyst fluid amylase concentration was lections, such as traumatic hematoma,
change in neurologic status. There 42,208 U/L and lipase concentra- lymphangioma, mesenteric cysts, or
has been some decrease in the num- tion was more than 200,000 U/L. ascites, as well as genitourinary ab-
ber of bowel movements. Physical Serum amylase and lipase values on normalities such as hydronephrosis
examination reveals a thin girl in ob- postoperative day 1 were 67 U/L and multicystic dysplastic kidneys
vious distress. Her temperature is (normal, 30 to 100 U/L) and (the most common causes of palp-
98.1°F (36.7°C), heart rate is 1,785 U/L (normal, 15 to 130 U/L), able abdominal masses in infants) or
110 beats/min, and blood pressure respectively. ovarian cysts, also should be consid-
is 110/60 mm Hg. Her Sexual Ma- Magnetic resonance retrograde ered. Many oncologic processes, such
turity Rating is 1. Her abdomen is cholangiopancreatography showed as lymphoma, leukemia, dermoid tu-
nondistended and intermittently normal pancreatic ductal anatomy. mors, Wilms tumor, neuroblastoma,
tender in the right lower quadrant, Cyst drainage, a prolonged course of and rhabdomyosarcoma, can result
with normal bowel sounds and a total parenteral nutrition, and for- in a solid abdominal mass. Primary
healing appendectomy incision. Back mula feedings via nasojejunal tube neoplasms of the pancreas such as pan-
and paraspinal muscle spasm are evi- resulted in resolution of symptoms. creaticoblastoma and pancreatic cyst-
dent. A radiologic study leads to her Jejunal feedings allowed the formula adenoma are rare in children.
diagnosis. to enter the intestine past the point
where the blood supply is shared The Condition
with the pancreas, avoiding the po- Pancreatic pseudocysts in children
Case 1 Discussion tential for pancreatic stimulation that usually are the result of trauma to the
An abdominal radiograph showed a can occur with feedings entering abdomen. Disruption of the pancre-
large, homogeneous mass arising higher in the GI tract. After 6 weeks, atic parenchyma with or without
from the left side of the abdomen, the patient had returned to his base- ductal injury may lead to the forma-
displacing the large bowel (Fig. 1). line diet by mouth and has had no tion of a nonepithelialized cyst. Non-
CT scan with intravenous contrast recurrence after 6 months. traumatic pancreatic pseudocyst can

index of suspicion
result from pancreas divisum (which drainage, internal drainage via cysto- any perianal itching. His symptoms
is associated with pancreatic ductal gastrostomy, or partial pancrea- resolved following two doses of me-
anomalies), acute or chronic pancre- tectomy. Among the nonoperative bendazole 2 weeks apart, and he had
atitis, or drug toxicity. The cause also approaches are bowel rest, hyper- no additional abdominal pain or
can be undetectable. Serum amylase alimentation, and octreotide, a drug bloody stool.
and lipase values often are normal or that reduces pancreatic secretion.
only slightly elevated. Suspicion for Outcomes are similar among these The Condition
pancreatic disease in this child could approaches, but the incidence of the Enterobiasis (pinworms) is the most
have been higher, based on the rela- disorder is too small to detect subtle common helminthic infection in the
tionship of vomiting to oral intake differences in therapy. United States. In preschool and
and the description of abdominal school-age children, their caregivers,
swelling that increased after attempts Lessons for the Clinician and institutionalized populations, in-
to eat. Although an uncommon cause of fection rates may be as high as 50%.
Pancreatic pseudocyst is a rela- abdominal mass, pancreatic pro- Most people infected with Enterobius
tively rare finding in children, with cesses, including pseudocyst, should vermicularis are asymptomatic or
approximately one case presenting be considered when there is a history have only rectal itching (10%). How-
each year at even large medical cen- of trauma, and imaging should be ever, rarely, some people afflicted
ters. In a review of the literature, 68% undertaken. The finding of a pan- with enterobiasis may present with
of the cases were the result of trauma, creatic pseudocyst should prompt in- abdominal pain or rectal bleeding.
20% were related to anatomic ab- vestigation for an episode of trauma This patient’s hemorrhagic colitis is
normalities, and the remainder were and evaluation of pancreatic anat- a very rare complication of enterobi-
labeled idiopathic. Although not omy. Surgical intervention and con- asis. It is unknown whether this pa-
precisely known, research indicates servative management appear to pro- tient’s initial fever was caused by his
that trauma induces local pancreatic vide similar outcomes. (David M. Enterobius infection. It is conceiv-
enzyme autodigestion, leading to Barrett, MD, PhD, The Children’s able that the pinworms took resi-
chronic pancreatitis and eventual Hospital of Philadelphia, Philadel- dence in and aggravated an already
pseudocyst formation. Some suggest phia, Pa.; Christine S. Cho, MD, ulcerated mucosa caused by another
that pancreatic pseudocyst in chil- MPH, Children’s Hospital and Re- condition, although there was no
dren that has no anatomic cause or search Center Oakland, Oakland, evidence of such a condition, and a
known history of trauma should raise Calif., UC San Francisco, San Fran- variety of studies indicate a connec-
suspicion for nonaccidental trauma. cisco, Calif.) tion between pinworm infestation
A history of no recent injury can and abdominal pain.
be misleading because some cysts de- A 2006 retrospective cohort study
velop weeks to months after the in- Case 2 Discussion of children who underwent colonos-
citing trauma. Common mechanisms The differential diagnosis of abdom- copy because of concern for inflam-
of injury include handlebar impact, inal pain includes anatomic, infec- matory bowel disease found 17% to
sports trauma, falls from a height, tious, inflammatory, metabolic, neo- be infected with E vermicularis ac-
and nonaccidental trauma. On fur- plastic, and functional causes. The cording to direct visualization on
ther review of imaging, the patient patient’s 2-week history of nonpro- colonoscopy. (1) As in this patient,
was found to have mild deformities gressive, severe abdominal pain, none of the children infested with
of the lateral left 8th and 9th ribs, bloody stool, and weight loss, cou- E vermicularis had rectal itching,
consistent with trauma in the past. pled with his physical signs and nor- instead presenting with abdominal
Although the parents could not recall mal CT scan findings, made acute pain (73%), rectal bleeding (62%),
a specific event, previous unnoticed processes such as appendicitis less and weight loss (42%). In addition,
accidental trauma was believed to be likely and raised concern for inflam- 50% had chronic diarrhea. After
the probable cause of his pseudocyst. matory bowel disease. An esophago- treatment with mebendazole, the
gastroduodenoscopy and colonos- symptoms of 83% of the patients in
Management and Therapy copy were performed and showed this study resolved.
For symptomatic pseudocysts, man- proctitis and pinworms in the cecum. One case report described right
agement techniques include CT- Biopsy showed nonspecific colitis. lower quadrant pain in a patient who
guided drainage, external surgical On further questioning, he denied was found to have pinworms in the

index of suspicion
cecum, with resolution of abdominal The test should be performed af- itching (10%), children may present
pain after a course of albendazole. ter the patient has been asleep for a on rare occasions with isolated ab-
(2) Additional studies have pointed few hours or early in the morning dominal pain. Rarely, pinworms can
out that enterobiasis may produce before the patient has passed a bowel lead to appendicitis or extraintestinal
symptoms resembling acute appendi- movement or bathed to increase sen- symptoms. An ova and parasites ex-
citis or produce extraintestinal infec- sitivity. A single test has a sensitivity amination is not sensitive and detects
tions, including those of the female of approximately 50%, increasing to only 10% of patients who have pin-
genital tract, although enterobiasis is nearly 90% if carried out on three worms. Pinworms are detected with
not a common cause of acute appen- consecutive mornings. In contrast, 90% sensitivity by using the “cello-
dicitis, as once was believed. (3)(4) pinworms rarely are detected on a phane tape test” on three consecu-
(5)(6) stool ova and parasites test, which has tive early mornings. Treatment, in
Understanding the life cycle of a sensitivity of only 10%. some cases of the entire family,
E vermicularis helps clinicians to with two doses of mebendazole, py-
appreciate a possible cause-and-effect Treatment rantel pamoate, or albendazole given
relationship among abdominal Enterobiasis is treated with a one- 2 weeks apart in addition to washing
symptoms, rectal bleeding, and in- time dose of mebendazole (100 mg), all clothes and bed linens thoroughly
fection. People are the only natural pyrantel pamoate (11 mg/kg, maxi- is greater than 90% effective at elim-
hosts of pinworms, so infection oc- mum 1 g), or albendazole (400 mg inating the pinworms. (Nicolas
curs by human-to-human transmis- for patients older than 2 y). When Brown, MS-IV, Su-Ting T. Li, MD,
sion. Adult pinworms reside and the dose is repeated in 2 weeks to MPH, University of California,
mate primarily in the human cecum. treat any possible reinfection, the Davis, Sacramento, Calif.)
Egg-laden females eventually mi- cure rate is 90% to 100%. In situa-
grate through the digestive tract to tions of multiple or repeated infec-
the anus, from which they make noc- tion, all members of the patient’s References
turnal migrations to the perianal re- household should be treated; some 1. Jardine M, Kokai GK, Dalzell AM. En-
gion to lay their eggs. Eggs are in- clinicians treat the whole family rou- terobius vermicularis and colitis in children.
J Pediatr Gastroenterol Nutr. 2006;43:
gested from contaminated surfaces tinely. Experience with these drugs
610 – 612
and hatch in the small intestine. Chil- in children younger than 2 years of 2. Brown MD. Images in clinical medicine.
dren often self-infect themselves by age is limited, warranting special Enterobius vermicularis. N Engl J Med.
scratching the perianal area, transfer- consideration of risks and benefits 2006;354:e12
ring the eggs on their fingernails to before administration. 3. Arca MJ, Gates RL, Groner JI, Ham-
mond S, Caniano DA. Clinical manifesta-
the mouth. In some cases, eggs may Because reinfection can occur eas-
tions of appendiceal pinworms in children:
become airborne and infect other ily, prevention techniques should be an institutional experience and a review of
people when they are inhaled. discussed with the family at the time the literature. Pediatr Surg Int. 2004;20:
of treatment. Patients should change 372–375
Diagnosis their underwear, pajamas, and bed 4. Yildirim S, Nursal TZ, Tarim A, Kayasel-
cuk F, Noyan T. A rare cause of acute ap-
E vermicularis infection usually is sheets frequently and bathe in the
pendicitis: parasitic infection. Scand J Infect
diagnosed by the “cellophane tape morning to decrease the egg load Dis. 2005;37:757–759
test,” which involves applying the and the chance of reinfection. Good 5. Das DK, Pathan SK, Hira PR, Madda JP,
sticky side of clear (not translucent) hand washing, keeping fingernails Hasaniah WF, Juma TH. Pelvic abscess
cellophane tape repeatedly to the trimmed, and trying to avoid scratch- from Enterobius vermicularis. Report of a
case with cytologic detection of eggs and
perianal skin to recover eggs. The ing the perianal area and biting fin-
worms. Acta Cytol. 2001;45:425– 429
tape is placed onto a slide to visual- gernails help decrease autoinfection. 6. Mahomed AA, MacKenzie RN, Carson
ize the “bean-shaped” eggs under a LS, Jibril JA. Enterobius vermicularis and
microscope. Alternatively, one can Lessons for the Clinician perianal sepsis in children. Pediatr Surg Int.
use a paddle swab or a pinworm Pinworm infestation should be con- 2003;19:740 –741
paddle (or make a pinworm paddle sidered in children experiencing ab-
by doubling the sticky side of clear dominal pain, even if they do not
cellophane tape over a tongue de- have perianal itching. Although most Case 3 Discussion
pressor) and apply the sticky surface children who have pinworms are Transabdominal ultrasonography re-
to the perianal opening. asymptomatic or have only perianal vealed absence of blood flow to the

index of suspicion
right ovary, which was enlarged and ovarian torsion. Abdominal pain is
contained a 3.9-cm unilocular cyst. the most common presenting symp-
Exploratory laparoscopy confirmed tom. Radiation of such pain to the
the diagnosis of ovarian torsion. back, flank, or groin is characteristic.
As with appendicitis, the girl experi-
Risk Factors encing ovarian torsion often has nau-
Masses (cysts and tumors) are the sea, vomiting, and pain, frequently
most common predisposing factor in coming in waves. Fever and an ele-
girls who develop ovarian torsion. vated white blood cell count are vari-
However, in a recent retrospective able features that may indicate the
review, more than 50% of all pa- occurrence of necrosis. Palpable ad- Figure 2. Detorsed ovary, showing re-
turn of circulation.
tients had no masses. (1) One nexal masses can be a presenting fea-
theory is that masses potentiate a ture because of the abdominal loca-
cause of the risk of retorsion or
greater risk for torsion by increasing tion of the ovaries in prepubertal
infection that can result from necro-
the ovary’s mobility on its pedicle. In children.
sis of an ovary that has not been
addition, fallopian tubes in children
reperfused successfully. Ovaries that
tend to be relatively long, also fos- Diagnosis
show advanced necrotic changes
tering increased mobility. Anecdot- Once ovarian torsion is suspected,
may require removal. When the
ally, strenuous exercise may be as- supporting imaging should be sought
torsed ovary contains a mass, cystec-
sociated with ovarian torsion, as expediently. Pelvic ultrasonography
tomy may be indicated. Oophorec-
demonstrated in testicular torsion. with Doppler flow studies is the pre-
tomy should be avoided when possi-
Sudden increases in intra-abdominal ferred imaging modality. The most
ble because masses in children rarely
pressure and abdominal trauma caus- common finding is enlargement of
are malignant.
ing organ movement also have been the torsed ovary, not a decrease in
In this patient, exploratory lapa-
suggested to play a role. Given the flow, as with testicular torsion. In
roscopy showed right ovarian tor-
higher incidence of right ovarian tor- one retrospective pediatric study,
sion with four twists of the vascular
sion, some have speculated that the 62% of the torsed ovaries continued
pedicle and a large right ovarian
sigmoid colon serves as a protective to show flow during diagnostic ab-
cyst (Fig. 3). Ovarian detorsion was
factor for the left ovary. In the pre- dominal ultrasonography. (2) In the
performed. Because the ovary was
pubertal girl, the ovaries are located absence of access to ultrasonography
severely edematous, cyst drainage
in the abdomen and more prone to to diagnose a potentially compro-
was performed instead of cystec-
torsion. mised ovary, surgical consultation
tomy. The cyst wall also was biop-
should not be delayed.
sied. Less than 24 hours postop-
Pathogenesis
eratively, the girl experienced a
Compression of the ovarian suspen- Therapy
recurrence of lower abdominal pain
sory ligaments affects lymphatic and Following diagnosis, varying surgical
and back spasm. Repeat ultrasonog-
venous drainage prior to compres- therapeutic approaches have been
raphy showed decreased flow to, and
sion of the thicker-walled muscular used. Ovarian conservation surgery
enlargement of, the right ovary, with
arteries. As venous return decreases, has been shown to be both safe
pain and ovarian engorgement oc- and efficacious in a number of stud-
cur. When arterial supply is com- ies. (3)(4) The arterial supply may
promised, ischemia develops and can not be occluded completely, despite
advance to infarction, necrosis, hem- congestion of drainage systems. Fre-
orrhage, and infection. Because the quently, ovaries that appear dusky
timing of these events often is not intraoperatively have been reper-
evident, salvaging an ovary always fused successfully. Once successfully
should be attempted. detorsed, recovery of blood flow,
gradual reduction in size, and return
Clinical Presentation to the normal color can be appreci-
Nonspecific clinical presentations of- ated (Fig. 2) Close observation fol- Figure 3. Torsed ovary, showing twist-
ten pose a challenge to diagnosing lowing detorsion is important being and large cyst.

index of suspicion
no evidence of a cyst. Laparoscopy not identified. Combined oral con- productive and hormonal compro-
was undertaken again and revealed a traceptive pills have been shown to mise. (Selvi Senthilnathan, MD, Todd
purple, edematous right ovary con- have a protective effect on the num- M. Poret, MD, Jodi K. Wenger, MD,
taining hemorrhagic debris. Right ber of functional ovarian cysts in Dartmouth Hitchcock Medical Center,
oophorectomy and salpingectomy postmenarchal girls through ovar- Lebanon, NH)
were performed. She did well post- ian suppression but not in premen-
operatively. Pathologic examination archal girls. Studies are needed to
revealed an infarcted ovary with be- demonstrate the efficacy of such ap- References
nign cysts. proaches. 1. Anders JF, Powell EC. Urgency of eval-
Due to this patient’s loss of an uation and outcome of acute ovarian torsion
Prognosis and Prevention ovary, she was advised on discharge in pediatric patients. Arch Pediatr Adolesc
The literature supports diagnostic to act quickly should she experi- Med. 2005;159:532–535
and surgical urgency as the key fac- ence any similar pain in the future to 2. Servaes S, Zurakowski D, Laufer MR,
tors in facilitating ovarian salvage, minimize the risk to her remaining Feins N, Chow JS. Sonographic findings of
ovarian torsion in children. Pediatr Radiol.
which has great variability in the de- ovary.
2007;37:446 – 451
gree of success. 3. McGowan L. Torsion of cystic or dis-
Some measures have been under- Lessons for the Clinician eased adnexal tissue. Am J Obstet Gynecol.
taken to prevent recurrences, in- Torsion of the ovary can present non- 1964;88:135
cluding oophoropexy and suppres- specifically and can be difficult to diag- 4. Way S. Ovarian cystectomy of twisted
sion of ovarian cysts with oral nose. An awareness of this entity as a cysts. Lancet. 1946;2:46
contraceptives. Oophoropexy is rec- cause of abdominal pain is the first step
ommended in all childhood cases in detecting its presence. Timely diag- To view Suggested Reading lists
in which a benign precipitant of the nosis and treatment are essential to for these cases, visit pedsinreview.org
torsion, such as an ovarian cyst, is preserve ovarian function and avoid re- and click on Index of Suspicion.
New Section Editor

Beginning July 1, 2008, the editing of “Index of Suspicion” will be
handled by Dr Deepak Kamat of Children’s Hospital of Michigan and
the Wayne State University School of Medicine. Inquiries regarding
potential case submissions should be directed to Dr Kamat at
dkamat@med.wayne.edu.

in brief
In Brief
Thumb and Finger Sucking
Lynn Davidson, MD prof/resources/pubs/jada/patient/ digit sucking does so. Pacifier use, but
Albert Einstein College of Medicine patient_77.pdf not thumb sucking, also has been found
Children’s Hospital at Montefiore to interfere with breastfeeding.
Bronx, NY Although the incidence of thumb suck- There are many theories about why
ing in developed countries has de- infants and young children engage in
clined in recent years, it remains a these behaviors. The psychoanalytic
Author Disclosure common behavior. Several related theory (Freud) posits that sucking is a
Dr Davidson has disclosed no habits—thumb sucking, finger sucking, newborn reflex and thumb sucking is a
financial relationships relevant to and pacifier use—are considered forms form of “infantile sexuality.” When it
this In Brief. This commentary does of nonnutritive sucking. Rates of non- persists past the oral phase of infancy,
nutritive sucking have varied over time. thumb sucking can be the result of an
not contain a discussion of an
Studies in the past suggested as many “emotional disturbance.” Another the-
unapproved/investigative use of a as 70% to 90% of children engaged in ory describes finger sucking as innate
commercial product/device. such behavior, with digit sucking more behavior that becomes a habit, a
common than pacifier use. Currently, learned behavior. Others note that be-
pacifier use is more prevalent. cause thumb sucking is soothing to the
Infant Oral Health and Oral Habits.
Thumb sucking is present in fetal life infant, the habit persists in some chil-
Norwak AJ, Warren JJ. Pediatr Clin
and has been noted at 29 weeks’ ges- dren when they are bored, tired, or
North Am. 2000;47:1052–1066
Repetitive Behaviors. Blum N. In: Levine tation. Recent studies have found finger- anxious.
M, Carey W, Crocker A, eds. sucking behaviors during infancy in For the most part, thumb and finger
Developmental-Behavioral Pediatrics. 10% to 34% of children. A large United sucking is a benign habit that has no
3rd ed. Philadelphia, Pa: WB Saun- States study found the prevalence of consequences or concern. However,
ders Company; 1999:430 – 433 pacifier use at 40% and digit sucking at children who suck their thumbs chron-
Finger Habits: Their Effects and Their 30% by the end of the first postnatal ically have a higher incidence of paro-
Treatments. Parts 1 and 2. Bishara year. This prevalence reversed by age 3 nychia, herpetic whitlow, irritant ec-
S, Larsson E. The Dental Assistant. years, when digit sucking was more zema, and accidental ingestion and can
2007;76 (vols. 1 and 2):14 –16, 18, prevalent than pacifier use, although develop calluses and, rarely, digital de-
and 16 –18, 20, 22, 24
both habits had decreased by this age. formities that require surgery.
Habit Reversal. Christophersen E. 2004.
By 4 years of age, only 12% of children The dental consequences of thumb
Development and Behavioral Pediat-
rics Online. Available at: www.dbpeds. in this study sucked their fingers; pac- and digit sucking were described in the
org/articles/detail.cfm?TextID⫽37 ifier use was reduced to 4%. 1870s. Dental changes in primary,
Changes in the Prevalence of Non- During the first few months after mixed, and secondary dentition include
nutritive Sucking Patterns in the birth, infant finger sucking happens malocclusions, such as posterior cross
First 8 Years of Life. Bishara SE, more during sleep. However, by the end bite, anterior open bite, and excessive
Warren JJ, Broffitt B, Levy SM. Am J of the first postnatal year, more infants overjet. It is not clear at what age such
Orthodont Dentofac Orthoped. 2006; suck their fingers while awake during changes become permanent. Many be-
130:31–36 the day. There is no difference in the lieve that if the habit is stopped by the
Thumb Sucking. Blenner S. In: Parker S, rate of the behavior between boys and age of 4 years, the changes are revers-
Zuckerman B, Augustyn M, eds. Behav-
girls, although girls may have more ible. Persistent changes in mixed and
ioral and Developmental Pediatrics.
trouble stopping the habit. Up to 50% permanent dentition depend on how
2nd ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2005:348 –350 of children who suck their thumbs or long a child has sucked his or her
For the Dental Patient . . . Thumb Suck- fingers do so while holding an object. thumb, how often the child sucks the
ing and Pacifier Use. Chicago, Ill: Although pacifier use may place in- thumb during the day, and the intensity
American Dental Association; 2007. fants and children at a higher risk for of thumb sucking. There also appears to
Available at: http://www.ada.org/ otitis media, no evidence suggests that be a genetic predisposition.

in brief
Older children who suck their nutritive sucking habits. Generally, palatal crib or rake, can be an excellent
thumbs are subject to social stigma. therapies are tailored to the child and reminder not to suck the thumb or
They may be ridiculed by peers as well often are combined. finger. Discussion should make clear to
as their parents, and they may be Positive reinforcement should be the child that the appliance is a re-
treated as immature and less socially given when the child is not sucking the minder and not a punishment. Palatal
acceptable. thumb or finger. Examples include appliances ideally should be placed
Treatment for thumb sucking should praise, small nonfood rewards, or stick- during the spring or summer, when
not be pursued before the child is 4 ers on a calendar for times when thumb other activities can distract the child.
years of age. Even in older children, if sucking is avoided. Another technique Usually 3 months with the appliance is
the behavior is infrequent or does not is for the older child or the parent to sufficient to change or eliminate the
interfere with dentition, cause social record every time the thumb is sucked;
thumb sucking, although some children
stigma, or harm self-esteem, therapy is positive reinforcement then should be
may need longer. A fixed appliance is
not necessary. given for decreases in the frequency of
more effective than a removable palatal
A variety of techniques can be used the habit. Negative or aversive thera-
appliance. The earliest a palatal appli-
to stop thumb or digit sucking if treat- pies include a bad-tasting substance
ance should be considered is during the
ment is sought. All techniques should put on the nails to deter or remind the
mixed or permanent dentition stage.
have the child as a willing and active child not to put the thumb or fingers
in the mouth. A variety of over-the- Complex dental changes should be re-
participant in the change in behavior.
Negative comments by the child’s par- counter nontoxic substances are sold ferred to an orthodontist.
ents can be counterproductive, rein- for this purpose. A sock, adhesive strip, Parents and pediatricians should re-
forcing the thumb sucking as an splint, or glove can be used to remind member that thumb sucking usually is
attention-getting technique. In addi- the child not to put the thumb or not problematic and that most chil-
tion, by not criticizing or ridiculing the fingers in the mouth. dren stop thumb sucking by 4 years
child, parents can lower tension and Once the child and parent are of age. For some other children, therapy
stress related to finger and thumb suck- aware of when the sucking habit oc- is indicated when thumb and finger
ing in the family. Parents should try to curs, a competing response can be used sucking becomes a psychological issue
discern when the thumb or finger suck- as an alternative to the thumb or finger or is having detrimental effects on den-
ing happens and what precipitates the entering the mouth. For example, tition. As with all therapies, ongoing
behavior. In particular, it should be squeezing an object whenever the monitoring is essential to ensure that
noted if the thumb sucking occurs child feels the impulse to thumb or the therapy is working, the technique is
when the child is bored, stressed, or finger suck can deter the unwanted appropriate for the child and family,
tired. Any relationship noted can help behavior. The efficacy of this technique and the intervention is not causing
target therapy. improves if practice sessions occur after more stress or psychological strain than
Positive reinforcement techniques, thumb or finger sucking and if a parent the problem itself. For pediatricians,
negative or aversive therapies, compet- monitors the child for the sucking be- that last condition is key, given the
ing response therapy, and dental appli- havior. generally innocuous sequelae to thumb
ances all have been used to treat non- If all else fails, an appliance, either a and finger sucking.

in brief
In Brief
Bacterial Vaginosis
Grael O’Brien, MD, PhD prevalence of BV range from 10% to form of a dense bacterial biofilm com-
University of Connecticut Health more than 50% of reproductive-age posed primarily of matrices of G vagi-
Center women. Between 25% and 50% of BV nalis, with substantial contributions of
Farmington, Conn. infections may remain asymptomatic. A vaginae. The anaerobic bacterial
BV is characterized by a complex overgrowth produces proteolytic en-
alteration of vaginal flora, with loss of zymes and decarboxylases that break
Author Disclosure the normally acidic (pH ⬍4.5) vaginal down vaginal peptides and convert
Drs O’Brien and Serwint have environment that is dominated by hy- them into volatile malodorous amines
disclosed no financial relationships drogen peroxide-producing lactobacilli, that, in turn, cause vaginal transuda-
relevant to this article. This which are protective against the over- tion and exfoliation of the biofilm-
growth of anaerobic bacteria. There is coated epithelial cells of the vaginal
commentary does not contain a
a shift to a less acidic (pH ⬎4.5), surface in the form of the classic
discussion of an unapproved/
anaerobe-dominated environment that bacteria-studded “clue cells” of BV.
investigative use of a commercial is populated by multiple bacterial spe- Although research supports BV as a
product/device. cies, including Gardnerella vaginalis, sexually transmitted disease, the role of
Mycoplasma hominis, Mobiluncus, and sexual activity in its pathogenesis re-
species of Prevotella, Bacteroides, Pep- mains unclear. G vaginalis is not iden-
Bacterial Vaginosis. Joesoef MR, Schmid tostreptococcus, Fusobacterium, and tified in prepubertal children who have
G. Clin Evid. 2005;4:489 – 491 Atopobium vaginae. A recent study re- been screened carefully for being at
An Altered Immunity Hypothesis for
ported that women who have symp- very low risk for sexual abuse. In con-
the Development of Symptomatic
Bacterial Vaginosis. Witkin SS, Lin-
tomatic BV are infected with an aver- trast, G vaginalis was identified by
hares IM, Giraldo P, Ledger WJ. Clin age of 13 different organisms. The culture in 24% of a group of sexually
Infect Dis. 2007;44:554 –557 diverse microbial profile of BV varies abused girls, of whom very few had
Risk Factors for Cervicitis Among remarkably by location, demographics, vaginal symptoms and among whom
Women With Bacterial Vaginosis. and other factors. the diagnosis of sexually transmitted
Marrazzo JM, Wiesenfeld HC, Murray In 1955, Gardner and Dukes de- infections (STIs) was very infrequent. In
PJ, et al. J Infect Dis. 2006;193: scribed the classic “clue cells” of BV the few studies of the epidemiology of
617– 624 and identified Haemophilus vaginalis, G vaginalis in men, the organism ap-
Sexually Transmitted Diseases Treat- later classified as G vaginalis, as the pears to have been identified in the
ment Guidelines, 2006. MMWR organism causing BV. For a period of genital tracts of approximately 3% to
Recomm Rep. 2006;(RR-11)55:1–95
time, the disease was simply known as 10% of men by miscellaneous detection
The Association of Atopobium vaginae
and Gardnerella vaginalis With Bac-
G vaginitis. Although we now know methods and in various contexts. BV
terial Vaginosis and Recurrence Af- that many organisms are associated occurs primarily in sexually active,
ter Oral Metronidazole Therapy. with BV, G vaginalis is its most sensitive reproductive-age females, particularly
Bradshaw CS, Tabrizi SN, Fairley CK, indicator and can be identified in vir- in women having new or multiple sex-
Morton AN, Rudland E, Garland SM. tually 100% of women who have BV. ual partners. BV can occur without
J Infect Dis. 2006;194:828 – 836 In contrast to the excellent sensitivity coitus; oral-genital and hand-genital
of G vaginalis for BV, its specificity of contact may be even stronger risk fac-
Bacterial vaginosis (BV) is the most 35% to 40% is mediocre, with up to tors for BV than penile-vaginal contact.
common infection of the reproductive 50% to 60% of healthy women who Among female sexual partners, there is
tract in females of child-bearing age have no symptomatic BV being infected a relatively increased incidence of BV
and is the most common cause of with G vaginalis. with a between-partner consistency in
symptomatic vaginal discharge in this The rising pH in BV facilitates at- vaginal flora. Factors other than sexual
group, accounting for approximately tachment of bacteria to the epithelial activity associated with BV include
40% to 50% of cases. Estimates of the surface of the vaginal mucosa in the douching and cigarette smoking.

in brief
The clinical significance of BV ex- Nugent scoring, based on Gram stain- women is controversial. Some experts
tends far beyond its causing annoying ing laboratory-submitted samples of advocate treatment of all women who
vaginal discharge. BV is associated vaginal secretions and grading speci- have BV regardless of the presence or
with numerous genital tract infections, mens by BV-like morphotypes, is con- absence of symptoms because of the
including increased susceptibility and sidered to be the diagnostic gold stan- enhanced risk of acquiring other STIs
transmission of Chlamydia infection, dard for BV. Other diagnostic methods and the risk of adverse gynecologic
gonorrhea, and oncogenic strains of include targeted DNA probes and rapid and obstetric complications. The cur-
human papillomavirus. BV enhances test diagnostic cards that indicate ele- rent CDC STI guidelines, however, ad-
the replication and vaginal shedding of vations of pH and amines. Because of vise that therapy for BV in nonpregnant
human immunodeficiency virus and the striking microbial heterogeneity in women be directed at relieving symp-
herpes simplex virus-2. BV pathogens BV, vaginal culture is far too nonspe- toms of infection and reducing the risk
ascend into the upper reproductive cific to be used to diagnose BV. of infection after abortion or hysterec-
tract and are associated with pelvic Additional clinical and microscopic tomy. To reduce the risk of premature
inflammatory disease; an increased in- clues, combined with determining the rupture of membranes and preterm
cidence of postpartum, postabortion, pH of the vaginal sample, help to dis- birth, the recommendation is to screen
and posthysterectomy infections; and tinguish BV from other common causes and treat BV only in pregnant women
postpartum and postabortion endome- of abnormal vaginal discharge such as who have a history of preterm birth.
tritis. An association between BV and candidiasis and trichomoniasis. Symp- However, screening and treating all
both premature rupture of membranes tomatic yeast infections, unlike BV, may pregnant women for BV has not ap-
and preterm birth may be mediated by present with pruritus, erythema, and of- peared to affect preterm birth rates.
chorioamnionitis. The increased suscep- ten a thick, white cottage cheese-like Studies indicate no benefits in treating
tibility to infection with genital tract vaginal discharge. Although candidiasis the sexual partners of women who have
pathogens and the associated adverse favors the normally acidic vaginal pH, it symptomatic BV.
gynecologic and obstetric outcomes in sometimes may coexist as a mixed infec- The most successful therapy for BV
BV are believed to be mediated through tion with BV in its less acidic (pH ⬎4.5) in nonpregnant women is metronida-
the induction of immune modulation vaginal environment (although this is un- zole, either 500 mg orally twice a day
and increased production of proinflam- common). However, this coexistence for 7 days (with a warning to avoid
matory cytokines. does not present in the opposite direc- alcohol consumption) or 0.75% intra-
Clinically, symptomatic BV presents tion; the diagnosis of candidiasis in a vaginal gel once a day for 5 days.
with a thin, homogenous, white-to-gray normally acidic (pH ⬍4.5) vaginal sample Metronidazole is particularly attractive
vaginal discharge that has an unpleasant, essentially rules out the diagnosis of BV for treating BV because it also eradi-
amine-associated “fishy” odor. Typically, (pH ⬎4.5). Trichomoniasis along with BV cates any coexisting trichomoniasis.
erythema, inflammation, and pruritus are is associated with an abnormally elevated Slightly less effective than metronida-
absent; only rarely is there dyspareunia or pH. Trichomoniasis may coexist silently zole is a 7-day course of intravaginal
dysuria. The Centers for Disease Control with BV, and clinicians should scan care- 2% clindamycin cream (with a warning
and Prevention (CDC)-recommended fully to rule out the coexistence of the that latex condoms may be weakened).
Amsel criteria (sensitivity ⬎90%, speci- other if either clue cells or trichomonads Clindamycin resistance and pseudo-
ficity 77%) require three of four criteria are identified on wet mount. Pruritus, membranous colitis are risks of clinda-
to diagnose BV clinically: 1) thin, white- dyspareunia, and a frothy, greenish, mal- mycin therapy. A 5-day 1-g/d oral
to-gray, noninflammatory, homogenous odorous discharge, combined with the course of tinidazole, a second genera-
discharge that smoothly coats the vagi- microscopic findings of trichomonads tion nitroimidazole, which has a longer
nal walls; 2) positive whiff-amine test and polymorphonuclear leukocytes, dis- half-life and fewer adverse effects than
(a “fishy” odor produced when a drop of tinguish symptomatic trichomoniasis metronidazole, is at least as effective as
10% KOH is added to vaginal discharge); from BV because BV typically is not as- metronidazole.
3) vaginal pH greater than 4.5; and sociated with inflammation. Treatment of BV can be very frus-
4) greater than 20% clue cells (bacterial- BV resolves spontaneously in about trating because a standard course of
studded epithelial cells) in saline wet one third of affected women. The goal either metronidazole or clindamycin re-
mount per high-power microscopic field in treating symptomatic females is to sults in a mediocre 60% to 80% cure
(most reliable of the four criteria). alleviate the unpleasant symptoms and rate. If symptoms resolve, test-for-cure
If microscopy is unavailable, alter- reduce the risk of infectious sequelae. is unnecessary. Unfortunately, relapse
nate diagnostic strategies are useful. Treatment of BV in asymptomatic with BV is very common; 30% of

in brief
treated women relapse within 3 months ence support this condition being a of bacterial vaginosis, the challenge
and more than 70% relapse within 7 global gynecologic and obstetric prob- to clinicians is to differentiate those
months. Women who have recurrent lem that warrants continued research. women who remain as asymptomatic
BV appear to be unable to recolonize There is a need to elucidate further the carriers from those who will become
their vaginas with the normal, hydrogen pathogenesis of BV, with several poten- symptomatic and are at risk to suffer
peroxide-producing lactobacilli that pro- tial goals. One is to develop reliable, sequelae and warrant treatment. An
tect against the overgrowth of anaero- inexpensive, and convenient identifiers alteration in innate immunity has been
bic bacteria. Unfortunately, lactobacilli of coinfection with the highly specific hypothesized as a possible explana-
supplements and yogurt do not con- G vaginalis and A vaginae combination tion for differences in response to the
tain the species of hydrogen peroxide- to predict those women who are at infection and progression to sequelae.
producing lactobacilli endemic to the particular risk for recurrence and ad- If this hypothesis were confirmed,
normal female genital tract (although verse gynecologic and obstetric out- genetic testing of women may be war-
they may help prevent the development comes. A second is to formulate more ranted to identify those who would
of candidiasis during prolonged anti- effective treatments that may pene- benefit most from treatment. Such
biotic courses for recurrent BV). Be- trate, disrupt, or dissolve the biofilm identification of at-risk women could
havioral modifications, including absti- matrix. A third is to develop realistic minimize unnecessary antibiotic expo-
nence and consistent condom use, may strategies for preventing BV, such as sure yet ensure that those at risk be
reduce the recurrence of BV. possible targeted vaccines. treated to prevent significant sequelae.
In summary, the well-documented Alternative strategies support the im-
association of BV with STIs and ad- Comment. This In Brief emphasizes portance of developing targeted vac-
verse gynecologic and obstetric out- the benefit of vaginal Lactobacillus to cines for protection from infection.
comes, its biofilm-associated recalci- maintain a healthy environment for
trance to treatment and eradication, the vagina and cervix. When this en- Janet R. Serwint, MD
and its frequently asymptomatic pres- vironment is altered by the presence Consulting Editor

in brief
In Brief
Meconium Aspiration
Douglas N. Carbine, MD Endotracheal Intubation at Birth for lowing the report by Gregory in 1974
Naval Medical Center Preventing Morbidity and Mortality of 88 consecutive infants who had
San Diego, Calif. in Vigorous, Meconium Stained meconium-stained amniotic fluid (MSAF)
Infants Born at Term. Halliday HL, and were intubated and suctioned in
Sweet D. Cochrane Database Syst
the delivery room. None of the infants
Rev. 2001;1:CD000500
Author Disclosure required ventilation, and there were no
Instructor’s Manual for Neonatal Re-
Drs Carbine and Serwint have suscitation. 5th ed. Zaichkin J. Elk fatalities. This result stood in contrast
disclosed no financial relationships Grove Village, Ill; Dallas, Tex: Ameri- to a historical rate of two to three
relevant to this article. This can Academy of Pediatrics/American deaths per year from MAS at that
Heart Association; 2006 institution. The obstetric practice of
oropharyngeal and nasopharyngeal suc-
discussion of an unapproved/ Evaluation of the current recommenda- tioning prior to delivery was introduced
investigative use of a commercial tions for delivery room management of soon thereafter.
product/device. deliveries complicated by the passage In 1976, Carson reported a com-
of meconium and how these have bined approach of suctioning on the
changed require an understanding of perineum, followed by intubation and
Meconium Aspiration in Infants-A Pro- the historical context in which the suction when meconium was verified at
spective Study. Gregory GA, Gooding original recommendations were made. the cords by direct viewing. They re-
CA, Phibbs RH, Tooley WH. J Pediatr. Meconium aspiration syndrome (MAS) ported one case of MAS out of a cohort
1974;85:848 – 852 remains a feared event that poses a of 273 MSAF deliveries and no fatali-
Combined Obstetric and Pediatric Ap-
considerable threat of morbidity to the ties. This result contrasted with a his-
proach to Prevent Meconium Aspi-
afflicted infant. The combined inflam- torical cohort of 18 cases of MAS out of
ration Syndrome. Carson BS, Losey
matory effect of meconium and me- 947 MSAF deliveries, with 5 fatalities in
RW, Bowes WA Jr, Simmons MA.
Am J Obstet Gynecol. 1976;126: chanical blockage of the airways often the MAS cases (27.8%). The apparent
712–715 leads to significant pulmonary disease positive effect on decreased mortality
Does DeLee Suction at the Perineum and the need for ventilator support. and the relatively benign nature of
Prevent Meconium Aspiration Severe disease may necessitate high these interventions resulted in their
Syndrome? Falciglia HS, Hender- ventilator settings, further damaging wide adoption. Although these and
schott C, Potter P, Helmchen R. the lungs through iatrogenic injury. similar studies were not prospective,
Am J Obstet Gynecol. 1992;167: When pulmonary hypertension ensues, case-control trials, many believed that
1243–1249 the need for aggressive support in- ethics prohibited additional clinical tri-
Oropharyngeal and Nasopharyngeal creases, and in the most severe cases, als. The belief was that MAS was a
Suctioning of Meconium Stained infants may require extracorporeal postpartum event that occurred with
Neonates Before Delivery of membrane oxygenation. Despite these the onset of respiration and that suc-
Their Shoulders: Multicentre, morbidities, mortality is relatively un- tioning prior to sustained respirations
Randomized Controlled Trial.
common where Level III neonatal inten- would prevent aspiration of meconium
Vain NE, Szyld EG, Prudent LM,
sive care unit care is readily available. to the lower airways.
Wiswell TE, Aguitar AM, Vivas NI.
Current mortality rates are considerably As these practices were adopted,
Lancet. 2004;364:597– 602
Delivery Room Management of the lower than the rates of 20% to greater data began to emerge that challenged
Apparently Vigorous Meconium- than 50% reported in the 1970s and the basic assumptions. In 1992, Fal-
stained Neonate: Results of the early 1980s. It is these statistics that ciglia compared early suctioning at the
Multicenter, International Collabo- must be considered when appraising perineum (prior to delivery of the tho-
rative Trial. Wiswell TE, Gannon CM, the early studies. rax) with late suctioning (after delivery
Jacob J, et al. Pediatrics. 2000;105: Routine intubation and tracheal suc- of the thorax). If aspiration occurred
1–7 tioning became common practice fol- with onset of breathing, early suction-

in brief
ing would be of benefit. These investi- ventilation for MAS, duration of venti- infant remains insufficient. Such in-
gators were unable to demonstrate any lator therapy, pneumothorax, other re- fants are at highest risk for in utero
advantage to suctioning before the spiratory disorders, duration of oxygen aspiration, and such an approach re-
thorax was delivered. A more plausible therapy, or length of stay. Currently, the mains prudent. Indeed, the NRP 2006
explanation, that MAS is an intrauter- American College of Obstetricians and recommendations state that if the in-
ine event, comes from experimental Gynecologists has no statement regard- fant is not vigorous (as defined previ-
data on animals. The fetal lung pro- ing routine suctioning at the perineum, ously), the clinician should suction the
duces fluid at a rate of 4 to 5 mL/kg per but results of the Vain study strongly trachea before additional resuscitative
hour. The bulk flow of fluid during suggest that this intervention is not efforts. If meconium is recovered, suc-
normal fetal breathing is up and out of effective. tioning should be repeated until little
the lungs and trachea. Experimental A study by Wiswell in 2000 com- additional meconium is aspirated or the
cord occlusion in fetal lambs and ba- pared routine intubation of vigorous heart rate no longer is stable. This
boons has stimulated gasping inspira- infants born through MSAF with no protocol remains the standard of care
tory breaths and aspiration of amniotic intubation. This prospective, random- until better scientific data to the con-
fluid. This observation suggests that ized trial, involving 2,094 infants, dem- trary emerge.
meconium aspiration occurs in utero as onstrated no difference in the rate of
a response to significant hypoxic or MAS, other respiratory distress, or com-
ischemic stress. It follows that when bined outcomes. Comment. MAS always has been
aspiration occurs, it happens before In 2002, the Cochrane Collaborative feared in the delivery room. What Dr
delivery and that suctioning at the group updated their meta-analysis of Carbine demonstrates so well is the
perineum will have no effect. Con- four studies (including the Wiswell study) value of evidence-based medicine and
versely, if the infant is not stressed, evaluating intubation for MSAF and the changes that have resulted in
normal fetal breathing and fluid move- concluded that routine intubation should guidelines as well-designed, random-
ment should make aspiration very un- be abandoned for vigorous term in- ized, controlled trials are performed.
likely. Delivery room intubation for fants. The 2006 Neonatal Resuscitation The more recent research suggesting
meconium in this setting should not be Program (NRP) of the American Acad- that MAS may be an intrauterine rather
necessary. emy of Pediatrics/American Heart Asso- than a postpartum event is fascinating.
The results of two recent multi- ciation recommendations are consis- Caring for the neonate in whom meco-
center, randomized trials lend support tent with this opinion, and current nium is noted at delivery is an impor-
to these theories. In 2004, Vain pro- recommendations are not to intubate tant collaborative effort between the
spectively randomized 2,514 infants, when the infant is vigorous (defined as obstetrician and pediatrician, and clear
comparing intrapartum oropharyngeal having strong respiratory efforts, good guidelines are essential.
and nasopharyngeal suctioning with no muscle tone, and a heart rate greater
suctioning of infants delivered through than 100 beats/min).
MSAF. They found no difference in the Evidence addressing the efficacy of Janet R. Serwint, MD
rates of mortality, need for mechanical intubation and suction in the depressed Consulting Editor

in brief
In Brief
Emetics, Cathartics, and Gastric Lavage
Perry Sheffield, MD Toxicologists. Clin Toxicol. 2005;43: on the lack of clear outcome improve-
Mount Sinai School of Medicine 61– 87 ment and known complications that
Manhattan, NY Position Paper: Whole Bowel Irrigation. can result from induction of emesis and
American Academy of Clinical Toxi- potential cardiotoxicity from multiple
cology and European Association of
doses of ipecac.
Poison Centers and Clinical Toxicolo-
Author Disclosure The revised 2003 recommendation
gists. Clin Toxicol. 2004;42:843– 854
Drs Sheffield and Serwint have Position Statement and Practice Guide- advocated that ipecac not be used in
disclosed no financial relationships lines on the Use of Multi-dose Ac- the home and that home supplies of
relevant to this article. This tivated Charcoal in the Treatment ipecac be discarded safely. The EAPCCT/
of Acute Poisoning. American Acad- AACT position paper on ipecac rec-
emy of Clinical Toxicology and Euro- ommends abandonment of its use by
discussion of an unapproved/ pean Association of Poison Centers emergency departments. Another panel
investigative use of a commercial and Clinical Toxicologists. Clin in 2005 offered guidelines for the use
product/device. Toxicol. 1999;37: 731–751 of ipecac after consultation with qual-
ified medical personnel only when
Of the more than 2 million exposures the following criteria are met: sub-
American College of Emergency Physi- reported to United States Poison Con- stantial risk of serious toxicity from
cians: Clinical Policy for the Initial trol Centers in 2003, more than 75% the ingestion; no access to an emer-
Approach to Patients Presenting were ingestions. Although most did gency department or alternative ther-
with Acute Toxic Ingestion or Der- not require referral to health-care fa- apy (eg, AC) for at least 1 hour; ad-
mal or Inhalation Exposure. Ann
cilities, the large number of those ministration within 30 to 90 minutes
Emerg Med. 1999;33:735–761
affected speaks to the need for scien- of the ingestion; and knowledge that
Guideline on the Use of Ipecac Syrup
tific consensus for management. This administration would not adversely af-
in the Out-of-hospital Management
of Ingested Poisons. Manoguerra AS, In Brief summarizes the current recom- fect later treatment, such as AC or
Cobaugh DJ, The Members of the mendations for gastrointestinal (GI) de- N-acetylcysteine.
Guidelines for the Management of contamination. The American Academy Contraindications to the induction
Poisonings Consensus Panel. Clin of Clinical Toxicology (AACT) and Euro- of emesis include medical conditions
Toxicol. 2005;43:1–10 pean Association of Poison Control that may be exacerbated by vomiting,
Poison Treatment in the Home. Com- Centers and Clinical Toxicology (EAPCCT) such as severe hypertension or brady-
mittee on Injury, Violence, and Poi- have issued position papers on GI de- cardia; a risk of or an acutely altered
son Prevention. Pediatrics. 2003; contamination that draw conclusions mental status; or ingestion of a sub-
112:1182–1185 based on the limited evidence regarding stance that is caustic, corrosive, or a
Position Paper: Cathartics. American the following modalities: emetics, gas- hydrocarbon. The primary complica-
Academy of Clinical Toxicology and tric lavage, activated charcoal (AC), ca- tions of ipecac therapy are aspiration
European Association of Poison thartics, and whole bowel irrigation. pneumonia and asphyxia. Other com-
Centers and Clinical Toxicologists.
Emetics, most commonly syrup of plications, such as cardiomyopathies
Clin Toxicol. 2004;42:243–253
ipecac, cause local gastric irritation, and arrhythmias, are associated more
Position Paper: Gastric Lavage. Ameri-
sensory receptor stimulation of the commonly with repetitive, nonthera-
can Academy of Clinical Toxicology
and European Association of Poison “vomiting center,” and chemoreceptor peutic use (eg, eating disorders, facti-
Centers and Clinical Toxicologists. stimulation in the floor of the fourth tious disorder by proxy).
Clin Toxicol. 2004;42:933–943 ventricle. The American Academy of Gastric lavage, or “stomach pump-
Position Paper: Single-dose Activated Pediatrics (AAP) lobbied for and ing,” involves use of a large-bore oro-
Charcoal. American Academy of Clin- achieved over-the-counter availability gastric (OG) tube to instill and aspi-
ical Toxicology and European Associ- of ipecac in the 1960s. Four decades rate warm saline (300 mL in adults
ation of Poison Centers and Clinical later, the AAP reversed its stance, based or 10 mL/kg in children). Alternately,

in brief
water may be used in adults but is not emesis. Complications of AC adminis- ments where WBI can be used to ex-
recommended in children due to the tration include aspiration pneumonia, pedite passage of the transported con-
risk of hyponatremia. The EAPCCT/AACT bowel obstruction (seen only in multi- tents. This use is relevant to the
does not endorse this method of dose use), and death from inappropriate pediatrician because adolescents some-
gastric decontamination due to lack OG tube placement. times engage in such smuggling activ-
of supporting evidence and potential Cathartics are substances that de- ities. Use of AC in combination with
risks such as laryngospasm, pharyn- crease absorption by accelerating the WBI for multidrug ingestion when some
geal or gastric perforation from pas- passage of the ingested substance. The agents are not adsorbed to AC or in
sage of the OG tube, and fluid and basic types of cathartics are bulk, lubri- conjunction with chelating agents for
electrolyte imbalances. The American cant, osmotic, and stimulant, all com- metal adsorption is being studied.
College of Emergency Physicians rec- monly known as laxatives. Of these Despite continuing controversy over
ommends reserving gastric lavage for types, only osmotic cathartics (eg, sor- best decontamination practices, con-
potentially life-threatening ingestions bitol, magnesium citrate) are addressed sensus remains on the importance of
that have occurred recently (generally by the EAPCCT/AACT position paper. toxic ingestion prevention and the im-
⬍60 min prior). Lavage may be pre- Studies of cathartic use for decontam- mediate consultation of a local poison
ceded and followed by use of AC. ination are limited; none has shown control center (toll-free in the United
Contraindications are the same as for specific benefit. Although the EAPCCT/ States: 1-800-222-1222) when inges-
ipecac. AACT concludes that cathartics gener- tions do occur.
AC is an organic product containing ally have no role in treatment of the
numerous micropores that allow a large poisoned patient, they acknowledge the Comment: This In Brief effectively
surface area of adsorption. AC is the opportunity for additional research on demonstrates the changes in recom-
only method of gastric decontamina- cathartic use in GI decontamination of mendations for decontamination tech-
tion supported by the EAPCCT/AACT slow-release products. Despite lack of niques. What first began as best expert
position papers. The AAP has discussed proven benefit, a single dose of osmotic opinion has resulted in policy changes
but not yet endorsed use of AC in the cathartic commonly is administered due to clinical research and demonstra-
home. Emergency department use is with AC. tion of lack of effectiveness and poten-
endorsed within 60 minutes of inges- Whole bowel irrigation (WBI), an- tial morbidity of some strategies. This
tion unless contraindicated because of other means of gastric decontamina- evolution serves as an example of the
the toxin consumed. AC is not for use tion, involves the enteral administration importance of continually evaluating
when the ingested substances are al- of an osmotically balanced solution, recommendations to ensure the safest
cohols, corrosives, iron, or lithium and most commonly polyethylene glycol. and highest quality of care to our
should be used with caution in hydro- Although not endorsing WBI in general, children. Although strategies such as
carbon ingestions, given the increased the EAPCCT/AACT position paper on child-resistant closure and the develop-
risk of complications from aspiration. WBI recommends that if used with AC, ment of safer medications have been
Dosing of AC typically is 0.5 to AC should be administered first, fol- instrumental in decreasing morbidity
1 g/kg up to an adult dose range of lowed by WBI, because some studies from ingestions, continued emphasis
25 to 100 g or a 10:1 ratio of AC to show reduced binding capacity of AC must be placed on passive strategies for
ingested toxin if the ingested amount is if solutions are mixed. One use of WBI prevention. Poison Control Centers re-
known. Patients can drink the AC slurry, has emerged in evaluation of “body main our most important partners; an-
and OG administration also is possible. packers,” individuals transporting illicit ticipatory guidance must emphasize to
Multiple doses of AC are useful for substances in their GI systems within families the importance of phoning
ingestions of substances that have sig- protective sheaths such as condoms, Poison Control Centers as an immediate
nificant enterohepatic recirculation, who are at risk of complications if the resource.
such as phenobarbital. AC is contrain- sheaths rupture. Law enforcement of-
dicated in patients who have unpro- ficers are bringing even asymptomatic Janet R. Serwint, MD
tected airways due to increased risk of body packers to emergency depart- Consulting Editor

Article psychosocial
The Difficult Pediatric

Encounter: Insights and Strategies
for the Pediatric Practitioner
Andrea Gottsegen Asnes, Introduction
MD, MSW,* Ambika All pediatric practitioners are familiar with the concept of the “difficult” encounter with a
Shenoy, MD* family. Such encounters can range from those that leave clinicians with a slightly uneasy
feeling once the family has left the office to those in which actual disputes occur. Barbara
Korsch, MD, wrote, “There are certain names on the day’s schedule that make the
Author Disclosure practitioner’s heart sink and feel fatigued in advance.” (1)
Although the responsibility of an effective partnership between pediatric practitioner
Drs Asnes and Shenoy
and parent is shared, the larger part of the task falls to the clinician. A recent policy
have disclosed no
statement published by the American Academy of Pediatrics (AAP) refers to pediatric
financial relationships clinicians as “privileged and trusted advocates for the well-being of children.” (2) With
relevant to this privilege and trust comes the responsibility to foster relationships with families and to
article. This fortify such relationships when they are threatened. The AAP states that “communication
commentary does not and collaboration” are principles of professionalism in pediatric practice to be upheld. In
addition, the statement says that pediatric practitioners must recognize that “patients’
contain a discussion
families and the health care team must work cooperatively with each other and commu-
of an unapproved/
nicate effectively to provide the best patient care.” (2)
investigative use of a Our own experience leads us to believe that although not all difficult encounters with
commercial families can be overcome or smoothed over, many can. Recognizing patterns of interaction
product/device. that can lead to conflict with parents and addressing them early can be highly effective in
preventing escalation. Many conflicts, once understood, even can lead to an enhancement
of the partnership between clinician and family.
The following case vignettes illustrate several types of difficult interactions with families
that we have had in our pediatric practices. Each is followed by suggestions that the
pediatric practitioner may find useful. Although it can feel awkward, even false, to try these
responses when faced with a challenging encounter, the results can be surprisingly and
happily effective.
The Justifiably Angry Parent

You are seeing well children in the office this afternoon. You had 10 newborns at the hospital
this morning (a practice record), and one who decompensated while you examined her had to
be admitted to the newborn intensive care unit. The traffic was terrible on the way back to the
office. It now is 2:00 PM, and your first appointment was scheduled for 12:30 PM. You enter the
examination room to find a red-faced mother with her sobbing 2-year-old.
It is a fact of life that sometimes, through no personal fault, practitioners significantly
inconvenience patients and families. Sometimes, as in the vignette, clinicians run late
because other, sicker children have commanded their attention and delayed their sched-
ules. This situation can be particularly challenging to manage effectively simply because a
mistake has not been made; instead, appropriate care to patients has been provided.
Practitioners know this and mistakenly can expect parents to know it, too. In our
experience, this expectation can lead to significant conflict with parents.
The most helpful first step in this common but unavoidable situation is to communicate
with families who may be inconvenienced. A timely call to the office staff to let the waiting
family know about the likely delay and to apologize demonstrates respect for the family’s
time. The parent should be offered a chance to reschedule the visit if he or she is unable to
wait.
The important point to remember when beginning an encounter with a family who has
been inconvenienced or frustrated is that no matter what the reason, the family has been
*The Department of Pediatrics, Yale University School of Medicine, New Haven, Conn.
Pediatrics in Review Vol.29 No.6 June 2008 e35

psychosocial difficult pediatric encounter
inconvenienced or frustrated. At times, we have been patient and parent demonstrates that you are willing to
unwilling or have seen others be unwilling to see this spend time and are speaking on even ground with them.
reality. Rather, we have focused on the validity of the Asking the mother to tell you more about how she is
reasons why the family has been kept waiting. In this feeling may reveal what is really bothering her. Simply
instance, the pediatrician has had a busy morning, and saying, “I can see that you are upset. Can you tell me
the healthy 2-year-old has not suffered ill consequences more about why you are upset?” will convey that you do
because of the delay. However, his mother has had an care about her feelings. It is possible that she has not
arduous 90 minutes trying to keep him happy in your made the changes you have suggested and is embarrassed
small examination room. The best initial approach is to that she has not done so. Now she may be able to tell you
apologize clearly and sincerely. Although the first urge is so. Or, she may be in denial that she even needs to make
to explain the delay, the explanation matters much less to the changes you have advised. Denial is a powerful de-
the mother than it does to the doctor. An explanation fense mechanism in a family’s arsenal of excuses for not
and an apology are not the same. making changes.
An apology does not come naturally when we have Although it is especially hard to take a caring and
not, in truth, made a mistake. Nor does apologizing sympathetic stance toward parents and patients who
mean that the practitioner must “admit” to making a speak angrily, these may be the very parents and patients
mistake. Failing to recognize this often has been the who need the most care and sympathy. Two simple
obstacle to prevent clinicians from ameliorating this statements may diffuse the initial anger: “Changing the
common situation. Knowing that we can be sorry that way you shop, eat, and cook can be very hard, and I
someone has been inconvenienced, yet neither being nor
realize I have asked you to do something difficult. Mak-
feeling at fault, has allowed us to say a sincere and
ing these changes is never easy for anyone.” The mother
effective, “I am sorry.”
then may be able to say that her son is her treasure and
that if he wants chips, then she wants to feed him chips.
She may say that she likes the way he looks now. It is also
The Nonjustifiably Angry Parent
important to keep in mind that many nutritious foods,
A 13-year-old boy is in your office for a weight check. His
such as fresh fruits and vegetables, are significantly more
body mass index is 35, and he has gained 4 lb since his last
expensive than many processed, less healthy foods. Some
visit with you. You have advised dietary changes and exer-
families may not have the resources to shop as they are
cise in the past. You report his weight to the patient and his
advised to by a well-intentioned practitioner and may be
mother and ask how the family is doing with implementing
your recommendations. The child tells you that he has been embarrassed to say so. All clinicians should be sensitive to
doing his best, but reports being limited by the amount of this possibility.
junk food “tempting him” in the house. After this state- No matter what the mother’s response, the situation
ment, his mother shakes her head and stares at you. She is likely to be about her son and her household rather
angrily says, “You doctors think you’re so great. What do than about the clinician. Once the subject of the visit has
you know about putting a healthy meal on the table? I make returned to its intended purpose, you can be supportive,
sure my children don’t go hungry. Sure they snack, but I put sympathetic, and helpful. Saying, “I know how busy you
dinner on the table every night. I’m not going to deprive are and I appreciate you taking time for this visit; we are
them.” together in this” shows respect for a parent’s time and
In the middle of a busy clinic session, clinicians can be openly refers to the partnership between clinician and
blind-sided by an unanticipated and unjustified angry parent.
response from a parent. The clinician in this situation is It even may be helpful to apologize to the mother,
at high risk of adopting a defensive posture and even which can be a particular challenge. Saying that one is
becoming angry in response to this unexpected attack. sorry about a perceived (but not delivered) insult does
The best possible course begins with an internal pause. not come naturally. This physician did nothing “wrong.”
Before responding, remember that although this parent However, expressing regret for inadvertently insulting a
is angry, she may not be angry with you. Take a breath. parent, even if doing so was beyond your control, con-
Have a seat and motion for them to do so, as well. Body veys that you care about his or her feelings. Try saying, “I
language speaks as loudly as words. Standing up or am sorry for appearing insensitive to you. I really do
pacing may be perceived as aggression or impatience. know how hard this is, and I want to be as helpful as I can
Sitting down and speaking calmly at eye level to the be to you and to your son.” An expression of regret from
e36 Pediatrics in Review Vol.29 No.6 June 2008

the clinician is powerful and often can change the emo- without his or her parent in the room. Once alone with
tional climate of a visit dramatically. the child, the ice may be broken with a statement such as,
Occasionally, a parent may not be able to move past “Tell me the top three places you would rather be than in
his or her initial anger. In these cases, focusing on the my office right now.” Letting a child know that you
child may be of some use. Stating, “We have the next understand his or her reluctance may pave the way to
20 minutes to care for your son. You and he have my common ground. Time spent recognizing and under-
undivided attention now, so we really should focus on standing the child’s unhappiness at being brought in for
him. His health is the most important issue,” while care sends a message that the clinician intends to serve
remaining neutral and calm may allow you and the family both the parent and the child. Once a dialogue is started,
to salvage something useful from the visit. it is significantly more likely that the child will open up
about whatever the parent’s concern is, even if he or she
The Angry Adolescent Patient is not ready to agree that the concern is valid. Even if the
A 15-year-old boy and his mother sit in an examination subject is not broached directly, such entrée may allow
room awaiting your entrance. As you grasp the doorknob, the patient to answer questions about his or her life,
you glance at the chart and read the chief complaint: friends, school, and activities that may, in turn, lead to
“Mother concerned about child’s behavior.” You enter the the reason for presentation on the child’s, rather than on
room to find the mother looking anxious and the boy looking the parent’s, terms.
disgusted. His arms are crossed in front of his body, and he If permission to do so is granted by a parent, a call to
studiously avoids making eye contact with you. His mother a teacher or school guidance counselor may provide
greets you and says, “Doctor, I so hope you can do something additional and helpful information. A person outside the
with him. I am at the end of my rope!” The boy glares at his family who has regular contact with the family may share
mother and then resumes an angry stare at the floor. crucial information that can help the practitioner to
Adolescent patients can present a new frontier of understand the nature of a problem and begin to address
challenging interactions for the pediatric clinician. When it effectively.
an adolescent patient is brought in for care by a parent
against his or her wishes, the stage is set for conflict. The Parent Who Refuses or Questions Care
Common parental concerns for which adolescents are A father brings his 6-year-old daughter to your community
evaluated under these circumstances include poor school health clinic for follow-up of severe eczema. She has been
performance, aggressive behavior, rebellious or defiant treated with topical corticosteroids, emollients, and un-
behavior, substance use or abuse, and health issues that scented and hypoallergenic cleansers. She returns with a
the child does not recognize. In each of these cases, the flare of her eczema, despite the multitude of therapies used
practitioner must obtain information from at least two in the past. Her father informs you that he refuses to put
sources: the parent and the child. In addition, informa- another drop of steroids on his daughter: “I read that they
tion from other sources, such as school personnel, may can cause growth problems; I don’t want my daughter to be
be helpful. small. I took her to see a naturopathic doctor, who promises
First, it is important for the clinician to hear from the she has a natural herbal regimen that will work and won’t
parent in this scenario about his or her concerns. This affect her hormones. We’ve tried your way, and it doesn’t
goal may be accomplished best with the child outside the help.”
examination room. Information gathered should include Superior care is the result of a trusting partnership
examples of the behaviors or symptoms that are worrying between parents and the pediatric practitioner. Preserv-
the parent as well as the experience of the parent regarding this partnership should be the top priority for a
ing these behaviors. If the child is behaving defiantly, practitioner faced with a doubting parent. However,
what impact has this had on the family? A careful review when one’s advice is challenged, this priority may fall by
of the family’s social situation may reveal a previously the wayside. Before the clinician becomes defensive, he
unrecognized source of stress to which the child is re- or she must make an effort to understand the parent’s
sponding. Are the parents arguing? Does a single parent reasons for rejecting a prescribed treatment. One reassur-
have a new partner? Even when a family is well known to ing factor in this particular situation is that the family has
the doctor, basic social questions must be asked. returned to the clinic for their doctor’s guidance, even as
Perhaps the biggest challenge in this scenario is to they question the wisdom of what he or she has sug-
establish a connection with the child. An important step gested. The practitioner, therefore, is in a position to
toward accomplishing this task is to speak to the child determine just what has provoked the father’s doubts

and possibly to repair his lack of faith. The best possible tions.” Such education can avoid conflict at a later date.
response is to ask questions that allow the father to Inviting patients and families to be included in discus-
explain, in his own words, what is bothering him. Re- sions regarding any aspect of their care helps to solidify a
member that his response may be unexpected, so try not successful parent/practitioner relationship.
to suggest responses. For example, say, “I know that this Patients and parents, of course, have a right to inquire
has been a difficult issue in your home. Tell me, what about their health and to broach alternative treatments
worries you the most about your daughter’s eczema?” about which they have heard. Perhaps an herbal therapy
This is different from saying, “I know that using steroids could be helpful in this situation. An offer to speak with
makes you worry about her growth.” the naturopathic doctor about the new regimen could be
Parents often have concerns that practitioners might educational for all parties. If it is certain that no harm is
never guess. The way to uncover these concerns is to ask associated with an alternative therapy, the clinician may
about them. Simply listening to a father’s concerns can be able to endorse it. When the practitioner realizes and
be cathartic for him. If he expresses frustration, validate respects that it is a patient’s or parent’s choice to pursue
his feelings and open up the discussion to reveal its alternative therapies, the door is left open for parents to
underlying causes. Giving a parent time to speak, without come to the practitioner with questions or concerns. In
interruption, is a nonconfrontational opening for real addition to prescribing treatments, the pediatric practi-
dialogue that should encourage the parent to reveal the tioner can be instrumental in educating patients and
source of his worry. For example, he may tell you that on parents about how to make informed decisions about
the radio he heard a news program about steroid- medical care.
induced growth retardation or that he saw a television
special on the bullying of short children. Perhaps facts The Negligent Parent
that he has heard recently have reanimated the trauma Your next patient in continuity clinic is a 9-month-old girl
from his own childhood of growing up as a smaller-than- who has only had her 2-month immunizations. You scan
average child. her chart and note multiple missed appointments as well as
Once the cause of anxiety has been identified, it documentation of repeated telephone outreach to the child’s
becomes easier to move toward a mutually satisfying mother by your office staff. You feel frustration, even anger,
outcome. Specific worries, once uncovered, can be vali- as you turn the handle on the door and enter the examina-
dated and addressed. Remember that although a physi- tion room.
cian may feel comfortable with standard regimens of A desire to help and care for children unites clinicians
therapy, family members may be troubled by them in who have chosen pediatrics as a specialty. Among the
different ways. For example, a child might be falling most challenging problems are parents who fail to care
asleep in school due to sedation from antihistamines or for their children. No matter the reason, the mother in
parents may be arguing over how to treat symptoms. Do this case has not acted to provide basic health care for her
not forget that parents may have a justified, and possibly child. A feeling of frustration is natural; even a feeling of
an unexpected, need to switch a course of treatment. anger can be understandable. Expressing these feelings,
Asking open-ended questions about the impact of an however, especially at the beginning of an encounter,
illness or of a prescribed treatment allows parents to talk may alienate the mother and inhibit future cooperation.
about their actual concerns that the clinician then can In the interest of the infant and of the clinician/parent
address directly. For example, “How has that antihista- relationship, the best approach is to assume a neutral
mine been working out? Do you have any concerns?” can stance and gather information.
be more productive than, “That antihistamine is really The tone that the clinician sets for this encounter may
helping, right?” have far-reaching consequences. Simply greeting this
Careful discussion of possible adverse effects is war- mother with a smile and a word about your happiness in
ranted prior to starting any new treatment. Helping seeing the baby again may defuse unspoken tension in
parents to know what to expect may prevent much the room. This mother knows that she has missed ap-
anxiety. Also, realistic expectations of the results of a pointments and that she has been unresponsive to your
prescribed therapy should be conveyed to parents: “Hy- staff’s efforts to get her to the office. She even may come
drocortisone ointment is a temporary solution for your in with a provocative stance as a way to guard against an
daughter’s eczema. She will require intensive moisturiza- anticipated rebuke from you. Greeting the infant
tion therapy to continue to keep her skin healthy. Some warmly, even if you cannot greet the mother warmly,
patients require either higher doses or stronger medica- conveys your desire to help.

It is appropriate to address the poor compliance di- ask parents to recognize a problem that they do not
rectly, but by taking a neutral stance. Try saying, “I see perceive as a problem. In this case, the baby does not
that you have missed several appointments. Can you tell appear to be ill. Further, this mother has fed five other
me what happened?” We have heard many answers to children who are healthy. The practitioner must over-
this question. One mother was a victim of domestic come such obstacles and persuade this mother to alter
violence and was compelled to miss appointments by her her habits. One approach is to choose focus on one or
abusive partner when she had outward signs of trauma. two topics. Although leaving the infant unattended,
Another mother reported that she had been evicted from propping bottles, and using a cell phone in your office all
her apartment and had been living in a shelter, three bus are important, the clear priorities are giving excessive
connections away from the clinic. We learned of these water and feeding honey. Running through a laundry list
obstacles because we asked about missed visits from a of this mother’s “wrongs” is likely to anger and alienate
position of concern and with a desire to help. her and will not improve the infant’s nutrition. Try
Some parents, of course, do not have reasonable starting sentences about the baby’s failure to thrive with
answers to this question. They show no outward signs of “the baby” or the child’s name rather than “you,” and
financial hardship or other strife. The noncompliant par- also try using “we.” For example, “Clara is not gaining
ents who come to clinic, set the car seat holding the baby weight as she should, and I see how we can solve this
on the floor, and proceed to talk loudly on cell phones problem.” Contrast this with, “You are feeding her too
provoke the most frustration from practitioners. How- much water so she is not gaining weight.” Choosing
ever, these often young and unsupported parents may be words with care to prevent this mother from feeling
no less deserving of a caring practitioner’s help in seeing defensive will speed her understanding of the problem
the importance of attending health supervision visits and and help her to do what is right for her child.
keeping immunizations up to date. Recognizing the mother’s experience and comment-
Overall, we have found it helpful to remember, and to ing on it are likely to be helpful. “You have raised a lot of
remind our trainees, that the children do not fail appoint- children and clearly know how to take care of them”
ments. In the interest of helping all children to be conveys respect for her experience. “However, we have a
healthy, taking a charitable stand toward their parents is significant problem here that needs to be addressed.”
most likely to improve care for children. Once the possi- Showing her the growth chart may be helpful in this case.
ble reasons for missing visits have been discussed, the Concur with the mother that she has raised other chil-
practitioner can explain the importance of the visits and dren successfully, but note that each child is different and
immunizations. has his or her own unique issues. Although there was not
Certainly, some parents will be unable or unwilling to a problem in the past, there is a major issue now. A focus
comply with care, even when the practitioner has made on the uniqueness of this baby takes the spotlight off of
every effort to help them to do so. In these cases, a link to the mother’s behavior: “I know you know what you are
social services or a referral to the local child protective doing, but this baby is throwing us a curve ball. She is
services may be warranted. different and needs a different style.” This allows you to
give needed advice without criticizing.
The “Experienced” Parent
A 2-month-old is in your office for a health supervision visit.
You enter the room to find the baby lying on the examina- The Worried Parent of a Well Child
tion table next to a propped bottle and her mother sitting in You pick up your messages from the last several hours and
a chair across the room talking on a cell phone. You politely are disheartened to see that one mother has called . . .
request the mother to finish her call and begin the visit. again. She has a question about her son’s toileting habits.
When you ask about the baby’s diet, the mother reports that The message notes that your receptionist offered to have her
she gives her baby water frequently to avoid constipation. speak to your (excellent) nurse, but she insists on speaking
She also gives her 2 teaspoons of honey “because she is sweet.” with you. This woman has called you at least weekly, some-
Review of the baby’s growth chart indicates that she has times more, since her son was born 8 months ago. In addi-
failed to gain weight appropriately. As you begin talking tion to her health supervision visits, the mother has been seen
about the dangers of water and honey, you are interrupted. for urgent visits on an average of three times per month
“I have six children. They are all healthy, and they all ate since her infant was born. Her concerns have ranged from
the same things. I don’t need to hear this from you.” minor upper respiratory tract illnesses to worries about
One of the most challenging tasks in pediatrics is to constipation to questions about his skin, as well as countless

other issues. The boy has grown and developed well since an innocent heart murmur that has resolved can lead to
birth. You have no concerns about his well-being or health. the misperception that a child is more vulnerable to
Parents who repeatedly present their children for care illness than are others. Once identified, the clinician can
without evidence of true illness can be among the most address the previously unrecognized connection be-
frustrating with whom to interact. Pediatric clinicians are tween the antecedent event and the parents’ worries and
taught not to ignore the concerns of a parent; a worried educate the parents about the child’s health and more
parent always must be heard and addressed. However, reasonable interpretations of his or her signs and symp-
when it becomes clear that a parent’s degree of concern toms.
does not correspond to the child’s condition, the practi- Finally, parents may seek care for well children by
tioner’s response is likely to be one of irritation. In this using fabricated symptoms rather than exaggerated con-
case, a careful review of the encounters that have tran- cerns. These parents may be suffering from a mental
spired is likely to offer a clue about what underlies this health problem, and their children may be victims of
family’s overuse of the medical system, and where, along abuse. When parents ask that children have repeated,
a spectrum of worrisome causes, a particular family may especially invasive, diagnostic tests or procedures, or
fall. when children who have been well suddenly present with
One explanation that we have uncovered is an ongo- dramatic symptoms such as hematemesis or seizures,
ing discrepancy between the parent’s assessment, “My child abuse must be considered. Parents who have facti-
baby has a terrible illness, does not sleep well, won’t eat tious disorder by proxy (Münchhausen syndrome by
well, and won’t play!” and the clinician’s assessment: proxy) may fabricate or induce symptoms in a child to
“This is a well baby who has a viral upper respiratory tract prompt unnecessary interactions with the medical sys-
infection.” Both parties are correct. To a parent, an tem. (4) If a practitioner suspects abuse, prompt consul-
infant who has a viral upper respiratory tract infection tation with a child abuse specialist is indicated.
may be a catastrophe. He stops sleeping through the
night (as does the parent), he is cranky, and all the food
on which the clinician focused in the health supervision When The Clinician Misses or Makes an
visit is not being eaten. The infant even may have lost Incorrect Diagnosis
weight, and the practitioner always pays attention to his Your partner is covering the practice for the weekend. She
weight. The clinician knows that this is a minor, inter- calls you at home on Saturday morning to tell you that she
current illness that will resolve with no ill effects. The just examined a 3-year-old boy you follow at the hospital.
clinician who tells a parent of an infant who has a bad You saw him on Thursday for poor oral intake and malaise
cold that “it is just a virus” sometimes is sending the and diagnosed a viral illness. Your partner informs you
message that “he is not really sick.” With so much that the boy was seen in the emergency department over-
evidence to the contrary, and with so much discomfort at night and was diagnosed as having a ruptured appendix.
home, parents may present a child repeatedly until the He has had surgery, and a long-term course of intravenous
practitioner agrees that the baby is, in fact, unwell. We antibiotic therapy has been initiated.
have learned to tell such parents that we know how One of the hardest conversations to have with a
miserable their infants (and they) must be and to counsel parent occurs when the physician has been wrong. Par-
carefully about supportive care. Upon hearing that the ents and patients look to pediatric clinicians to be all-
baby is sick and having treatment prescribed, some par- knowing and benevolent. That harm can come to a child
ents no longer feel the need to present the child contin- under the care of a trusted health-care practitioner is
uously for care. unthinkable to most families. However, mistakes do
Further along on a spectrum of concern, the vulnera- happen. In this case, the physician missed the diagnosis,
ble child syndrome is a well-defined phenomenon that resulting in an unfavorable outcome. Pediatric clinicians
refers to “a physically healthy child who is viewed by his know that appendicitis is a tricky diagnosis to make in
or her parents as being at greater risk for behavioral, young children and may comfort themselves knowing
developmental, or medical problems, usually following a this. However, although this may be an understandable
serious childhood illness.” (3) This syndrome can be mistake, it still is a mistake.
identified by taking a careful history and uncovering an The affected practitioner should broach the subject
event, real or imagined, that has led to undue anxiety that a mistake has been made, take responsibility for the
about a child’s health. A difficult path to fertility, a error, and apologize to the family. Although the clinician
preterm birth, a hospitalization during infancy, and even can enumerate reasons for the mistake, including how

hard it can be to diagnose a certain problem in younger Summary

children, he or she should not articulate such reasons to These vignettes do not include every difficult encounter
the family, at least not initially. As has been said previ- confronted by the pediatric practitioner. They are of-
ously, an apology and an explanation are not the same fered as examples of an approach to handling such en-
thing. Families may ask for and benefit from an explana- counters. A unifying theme in these cases is the clinician’s
tion, but this does not diminish their right to an undi- obligation to take responsibility for diffusing and amelio-
luted apology. rating challenging, awkward, and frustrating interactions
In our experience, families are much more forgiving with families. Individual practitioners may choose differ-
of practitioners if they are swiftly forthcoming with a ent words than those we have offered. What matters is
description of the mistake and a simple, direct apology that clinicians see the role they have in improving rela-
for it. In this case, the clinician might best visit this tionships with families when relationships are stressed.
child and his family in the hospital immediately and say, Pediatric practitioners may not always feel generous,
“I did not recognize that your son’s appendix was in- sympathetic, caring, or contrite when interacting with
flamed on Thursday, and this has led to his need for an challenging families. Clinicians, however, need to treat
extended hospitalization. I am so very sorry for not these families with generosity, sympathy, care, and some-
having recognized it.” Many clinicians fear that admit- times, contrition. Doing so is not only an obligation, but
ting to a mistake and apologizing for it will lead to often results in a positive outcome to an initially negative
litigation by parents. In fact, recent evidence from med- encounter.
ical centers that have institutionalized full disclosure
programs suggests significant decreases in the number of ACKNOWLEDGMENTS. Dr Asnes gratefully acknowl-
malpractice cases and litigation costs since such programs edges the contributions of her father-in-law, Russell
have been implemented. (5) Asnes, MD, to this article.
Making a clinical mistake, particularly one that has
adverse consequences, is one of the most painful experi-
ences a pediatric practitioner can have. The feelings of
References
1. Korsch B. Difficult encounters with parents. In: Parker S, Zuck-
guilt and regret are very powerful, so clinicians may seek erman B, Augustyn M, eds. Developmental and Behavioral Pediat-
comfort by avoiding the family of a patient with whom a rics: A Handbook for Primary Care. 2nd ed. Philadelphia, Pa:
mistake was made. We suggest that this temptation, if Lippincott Williams & Wilkins; 2005:21–24
present, be identified and studiously avoided. Parents 2. Fallat ME, Glover J. American Academy of Pediatrics, Commit-
tee on Bioethics. Professionalism in pediatrics: statement of princi-
still need and trust a clinician who has made an error and,
ples. Pediatrics. 2007;120:895– 897
therefore, will feel abandoned if he or she pulls away. 3. Pearson SR, Boyce WT. Consultation with the specialist: the
Continued close attention to the family in the case while vulnerable child syndrome. Pediatr Rev. 2004;25:345–349
the boy recuperates is likely to be very well received by his 4. Stirling J, American Academy of Pediatrics Committee on Child
parents, although many practitioners do not perceive this Abuse and Neglect. Beyond Munchausen syndrome by proxy:
identification and treatment of child abuse in a medical setting.
to be the case. Making a mistake does not mean that the
Pediatrics. 2007;119:1026 –1030
clinician cannot continue to care for and about a family. 5. Wojcieszak D, Banja J, Houk C. The sorry works! Coalition:
Rather, continuing to care is likely to make all parties, making the case for full disclosure. Jt Comm J Qual Patient Saf.
including the practitioner, feel significantly better. 2006;32:344 –350

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What are the main articles discussed in the issue?

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Cover credits:The artwork on the cover of this month's issue is by one of the

Vol. 29, No. 6; June, 2008

183 Vomiting in Children:

209 Bacterial Vaginosis

e35 The Difficult Pediatric Encounter:

The printing and production of Pediatrics in Review威 is

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Table 1. Differential Diagnosis of Vomiting by Systems

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Age-related Differential Diagnosis of Vomiting in Children

Younger Than12 Months of Age

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Figure 1. “Double bubble” sign on plain radiograph, which

erance, and IHPS are discussed in greater detail in this

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of age. Intussusception is the telescoping of one portion

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receptor antagonists at the chemoreceptor trigger zone.

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Complementary, Holistic, and

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Clinical Trials of Naturopathic Ear Drops for Acute Otitis Media

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Table 2. Summary of Xylitol Intervention Trials

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Table 3. Summary of Homeopathic Interventions

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Table 3. Summary of Homeopathic Interventions (Continued)

Conclusion use of antibiotics and subsequent bacterial resistance.

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Case 1 Presentation diagnosis is made only after a proce-

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New Section Editor

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The Difficult Pediatric

The Justifiably Angry Parent

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