Author
Mark P. Brady, PA-C
Chief Physician Assistant
Department of Emergency Medicine
Cambridge Hospital
Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Amy Kao, MD
Attending Neurologist
Children's National Medical Center
Washington, DC
Disclosure: Amy Kao, MD, has disclosed no relevant financial relationships.
At 6 weeks of age, the average infant cries about 3.5 hours a day resulting in nursing problems, marital stress, postpartum depression, unnecessary emergency department (ED) visits, and shaken baby syndrome. The etiology of crying can range from benign to life-threatening. Fortunately, most irritable, crying children can be easily consoled and a cause readily found. When a child is not easily consoled, a selective workup based on findings from the history and physical examination is usually sufficient. The child should be completely undressed and thoroughly examined. The images shown are from a child with a hair tourniquet (left image, arrow) and then after removal (right image). Images courtesy of Wikimedia Commons.
Do the parents have long hair? A hair or thread can become tightly wrapped around an appendage and result in a hair tourniquet syndrome causing severe pain, injury, and sometimes loss of the appendage. Hair tourniquets often involve a finger but other appendages such as a toe, wrist, penis, scrotum, tongue, vaginal labium, ear lobe, umbilicus, or nipple can be involved. The blunt probe method (left image) is often used to release a hair tourniquet. The right image shows removal of a penile tourniquet (arrow) using the blunt probe method. In the blunt probe method, a blunt tip placed between the appendage and the scalpel ensures that the appendage is not inadvertently cut.
Will the child open his or her eyes? Does the infant have unclipped fingernails? Corneal abrasions often are the result of a foreign body or fingernail scratch and are one of the most common eye injuries. Caused by a disruption of the protective layer of corneal epithelium, corneal abrasions usually heal without complication. Deep corneal abrasions may result in scar formation of the stroma, the transparent middle layer of the cornea. The application of fluorescein dye (shown) can help make abrasions more visible.
Are both testicles palpable? Is there any scrotal asymmetry or erythema? Any evidence of tourniquet effect? Testicular torsion (arrow) is an acute vascular event in which the spermatic cord becomes twisted on its axis, so that the blood flow to/from the testicle becomes impeded. Torsion will often cause severe pain and can result in ischemic injury and infarction. Doppler ultrasonography is the most commonly used modality to evaluate testicular blood flow. The condition is a surgical emergency and may result in loss of the testis if not repaired within several hours of onset.
Are there any hernias palpated? This image reveals the typical appearance of an infant with a large right indirect inguinal hernia. The right scrotal sac is enlarged and contains palpable loops of bowel and fluid. All pediatric inguinal hernias require operative treatment to prevent the development of complications, such as inguinal hernia incarceration or strangulation, which can lead to bowel ischemia. Inguinal hernias will not heal spontaneously and inguinal hernia repair is one of the most common pediatric operations performed.
Bacterial meningitis is most common in infants under 1 year of age. While Group B Streptococcus, Escherichia coli, and Listeria monocytogenes are the most commonly involved bacteria immediately after birth, Streptococcus pneumoniae and Neisseria meningitidis are most common after 1 month of age. Signs are often hard to detect in young children who may present with persistent crying, irritability, lethargy, fever, or vomiting. Clinicians should have a low threshold for a diagnostic lumbar puncture in infants suspected of bacterial meningitis. This contrast-enhanced, axial T1-weighted MRI shows leptomeningeal enhancement (arrows).
Foreign bodies in the ears, nose, eyes, airway, and gastrointestinal tract are common causes of pediatric visits to EDs and carry a unique set of presentations and risks. These pediatric patients may only present with persistent crying. Clinicians must maintain a high index of suspicion for foreign bodies when history is not available or unreliable to prevent subsequent morbidity or mortality. Most ingested foreign bodies pass harmlessly through the gastrointestinal tract. However, if items become lodged, have sharp angles, or have associated toxicity they often must be removed. The image shown is of a child who ingested a button battery (arrow), with a characteristic step-off pattern of the battery in profile. Batteries must be removed because they may break down and release caustic materials.
Radial head subluxation, also known as nursemaid elbow, is the most common upper extremity injury in infants and young children who present to the ED. Reduction of the radial head is easily performed in the ED with few complications. Subluxation occurs after longitudinal traction is placed on a pronated extended arm. Alternative diagnoses should be sought if point tenderness or any obvious deformity is present. To reduce a radial head subluxation, first hold the elbow in 90 degrees of flexion with constant pressure on the radial head (arrow, left image). Next, supinate the wrist with the elbow still in 90 degrees of flexion (curved arrow, left image). Then flex the elbow completely (arrow, right image). The provider will often feel a "click" as the radial head falls into place on full flexion.
Intussusception is the predominate cause of intestinal obstruction in patients 3 months to 6 years of age and most cases (90%) are idiopathic. Most cases of intussusception occur at the terminal ileum, with the telescoping proximal portion of bowel (the intussusceptum) invaginating into the adjacent distal bowel (the intussuscipiens). The mesentery then becomes compressed, causing swelling of the bowel and obstruction. Eventually, venous engorgement and ischemia of the intestinal mucosa cause bleeding and secretion of mucous, resulting in the classic description of "currant jelly" stool. This ultrasound reveals the classic target sign (arrow) of an intussusceptum inside an intussuscipiens.
Colic is an ill-defined entity of unknown etiology. It is generally associated with the following signs and symptoms: episodes of paroxysmal inconsolable crying beginning at 1-2 weeks of age and resolving by 4 months; crying concentrated in the late afternoon and evening; and associated behaviors of arching back, flexed legs and clenched fists, grimacing, regurgitation, distended abdomen, and passing gas. A strategy that involves the 5 S's -- shushing, swinging, swaddling, sucking, and side/stomach positioning in the parents' arms -- seem to calm most crying infants. Recent studies show that treatment with Lactobacillus (shown) probiotics decreases infants' crying time greater than the standard therapy, simethicone.
An infant with otitis media may present with persistent crying, difficulty sleeping, and loss of appetite. Infants may push their bottles away as pressure in the middle ear makes it painful to swallow. Studies show that otitis media will develop in 61% of pediatric patients with an upper respiratory infection. Allergies and viral illnesses can cause swelling within the eustachian tube, resulting in the buildup of fluid in the middle ear. This creates a haven for bacteria and viruses, which can cause infection resulting in significant discomfort to the child. A healthy tympanic membrane appears translucent and pinkish-gray (left image). In otitis media (right image), a purulent effusion (arrow) may be visible behind a bulging, erythematous tympanic membrane.
Fluid and pressure buildup in the middle ear can result in a ruptured tympanic membrane (arrow, left image). Signs of a ruptured tympanic membrane may include white, yellow, or brown fluid draining from the ear. Pain may disappear as pressure on the tympanic membrane is resolved. Most ruptured tympanic membranes will heal in a couple of weeks. Otitis media with effusion, also known as glue ear, refers to a buildup of fluid in the middle ear without any pain and often follows an acute ear infection. The fluid will usually clear up on its own. Persistent otitis media with effusion and chronic otitis media can result in scarring of the eardrum. Hearing loss and tympanostomy tubes (right image) may be needed to help drain the fluid.
A urinary tract infection is one of the most common infections in childhood. In the first few months of life, a persistently crying afebrile infant should undergo urine evaluation. In older children, investigations should be performed on the basis of clinical findings. Neonates and infants from birth to 2 months who have a urinary tract infection cannot localize symptoms and the infection is often discovered as part of an evaluation for neonatal sepsis. In some infants with urinary tract infection, fever may be the only presenting symptom, while other children are acutely ill with a history of crying, irritability, decreased oral intake, vomiting, and loose bowel movements. The image shown demonstrates bacteriuria (red arrow) and pyuria (yellow arrow) on urinary microscopy. Image courtesy of Wikimedia Commons.
In most diaper rashes, the etiology is not clearly defined. Most likely it is the result of a combination of wetness, friction, urine and feces, and the presence of bacteria. In infants, this area of the skin has numerous folds and creases, which can make keeping the area clean and dry difficult. A 3-week-old female infant with diaper rash is shown. Satellite lesions, typical of yeast infections, can be observed. The patient was diagnosed clinically with candidal dermatitis and successfully treated with nystatin ointment.
Teething can often cause an infant significant distress. The swelling before a tooth erupts is usually the cause for the pain and fussiness that some babies experience. Symptoms usually begin 3-5 days before a tooth erupts and disappear when the tooth breaks the skin (arrow). Common symptoms include crying, fussiness, drooling, restless sleeping, mood changes, and occasional fever. Teething can begin as early as 3 months of age. Image courtesy of Wikimedia Commons.
Herpangina most commonly affects infants and young children 3-10 years of age. Herpangina is a pharyngeal infection typically caused by various enteroviruses, and is associated with small, painful vesicular or ulcerative lesions on the posterior oropharynx (arrow). Hyperemia of the pharynx is associated with lesions that characteristically appear as discrete erythematous-based macules. Fortunately, herpangina is self-limited and treatment involves antipyretics or topical analgesics.
Color Atlas of Pediatric Dermatology
Samuel Weinberg, Neil S. Prose, Leonard Kristal
Copyright 2008, 1998, 1990, 1975, by the McGraw-Hill Companies, Inc. All rights reserved.
Patients with hand-foot-and-mouth disease present with lesions to the oral mucosa and the skin usually caused by a coxsackievirus. The oral lesions are painful or painless vesicles that may ulcerate on the buccal mucosa (arrow) and the base of the tongue. Cutaneous tender macules or vesicles then develop on an erythematous base and a high fever develops for 24-48 hours. Like herpangina, diagnosis is clinical and treatment is supportive with antipyretics and analgesics.
Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology
Klaus Wolff, Richard Allen Johnson, Dick Suurmond
Copyright 2005, 2001, 1997, 1993 by The McGraw-Hill Companies. All Rights reserved.
Children aged 3 years and under have the highest rates of abuse. More than 3 million reports are made to child protective authorities in the United States each year. Radiography can be helpful in detecting physical abuse, particularly because skeletal fractures are so prevalent. The skull, ribs, and long bones of the arms and legs are the most common areas of injury. Pediatric bones are more porous than adult bones, making them more susceptible to compression fractures. It is important to try to date any fractures found to correlate with the presented history. A bone fracture that has already formed a callus, as shown in the radius and ulna of this child (arrows), is inconsistent with the history of a recent injury. A pediatric radiologist would be able to best estimate the age of a fracture.
Skull fractures may be the result of accidental trauma or abuse, so it is important to carefully correlate with the history. If the mechanism is a fall, the height of the fall must be carefully considered because falls from heights less than 2 ft rarely produce skull fractures. Because of the intramembranous nature of the skull, skull fractures do not heal with the typical callus formation present in long bones making it more difficult to date the age of fractures (arrow).
An 8-month-old infant is brought into the ED by his mother with a history of having fallen from a changing table. Note the acute transverse midshaft humerus fracture (arrow). This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap. Treating the physically abused child can be viewed as a series of diagnostic and therapeutic steps. These include suspecting abuse, establishing the diagnosis, treating injuries, addressing safety issues, reporting to appropriate child protective agencies and law enforcement, documenting findings, and recommending follow-up treatment.
Ophthalmologic examination provides valuable information in any case of suspected child abuse. If possible, a dilated exam is preferred, but retinal examination with direct ophthalmoscopy is still very helpful. Retinal hemorrhages (arrow) are diagnostic of shaken-baby syndrome until proven otherwise. Papilledema, if present, indicates increased intracranial pressure and the need for additional workup or imaging.
Birth trauma should be considered as a potential cause of subdural hematomas. Approximately 25% of healthy, full-term, vaginally delivered term infants have the potential to develop asymptomatic acute subdural hematomas that can evolve into chronic subdural hematomas, but these typically resolve in 1-3 months. A subdural hematoma (arrows) can also be a feature of shaken baby syndrome. The usual presentation may be one of crying, irritability, new-onset seizures, increased head circumference, poorly thriving infant, and tense fontanel. Focal neurologic deficits are usually absent. Children presenting without a history of trauma, a trauma history inconsistent with the child's injury or a history that changes during retelling, should prompt a healthcare provider to consider nonaccidental trauma.
It is important to get an accurate description of the mechanism of injury and the timeline involved. Physical examination may show burns, bites, bruises, broken bones, or black eyes in various stages of healing. Specific bruising or burn patterns are helpful to distinguish abuse from accidental injury. The child shown has a well-circumscribed burn injury from a cigarette lighter.
Author
Mark P. Brady, PA-C
Chief Physician Assistant
Department of Emergency Medicine
Cambridge Hospital
Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Amy Kao, MD
Attending Neurologist
Children's National Medical Center
Washington, DC
Disclosure: Amy Kao, MD, has disclosed no relevant financial relationships.
Can't-Miss Common-to-Rare Skin Conditions in Infancy
Common and Dangerous Childhood Inflammatory Disorders
Foreign Objects Found in Patients
Infectious Skin Conditions Not to Miss
Pediatric Rashes to Worry About
