Failure to Thrive

Smith AE, Gossman WG. Failure To Thrive. 2017 Oct 6. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.

Failure to thrive (FTT) is a common term used to describe lack of adequate weight gain in pediatric-aged patients. Accepted definitions include a weight for age less than the fifth percentile on standardized growth charts, a decrease in weight percentile of more than two major percentile lines on the growth chart, or less than the 80 percentile of median weight for height ratio weight/length ratio. Failure to thrive is important to recognize and treat because it can result in developmental delays and other long-term effects for the developing child.

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Pulmonary embolism in sickle cell disease

Tivnan P, et al. Imaging for Pulmonary Embolism in Sickle Cell Disease: a 17-Year Experience. J Nucl Med. 2018 Feb 1. pii: jnumed.117.205641.

In sickle cell disease patients with suspected pulmonary embolism, positive imaging rates were low for any given clinical presentation, but 11% of the cohort was diagnosed with pulmonary embolism over the 17-year study period. CTPA and V/Q performed comparably for pulmonary embolism diagnosis when the choice of imaging was guided by results of chest radiography. Hence, V/Q is a reasonable first choice for sickle cell disease patients with normal chest radiographs.

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Hematuria

Davis TK, Hmiel P. Pediatric Hematuria Remains a Clinical Dilemma. Clin Pediatr (Phila). 2015 Aug;54(9):817-30.

“Hematuria in the pediatric population is a common clinical dilemma for the clinician. The clinician should attempt to categorize it further into gross versus microscopic, symptomatic versus asymptomatic, and transient versus persistent. Gross hematuria if confirmed to be persistent, regardless of symptoms, almost always warrants further diagnostic testing. A standardized approach toward microscopic hematuria cannot be recommended. The differential diagnosis is too broad. Recommendations toward screening for asymptomatic hematuria have been dynamic, but currently, the AAP recommends against screening.4 Although it is never normal to have blood in the urine, isolated microscopic hematuria is rarely an indicator of significant kidney disease. Admittedly, this can be difficult to convey to skeptical patients and families, but invasive diagnostic procedures are unlikely to yield a treatable diagnosis or guide management. Reassurance is warranted. However, reassurance without periodic follow-up is no longer acceptable because long-term data have now identified an overall small but statistically significant risk of chronic kidney disease progression during long-term follow-up.”

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Staphylococcal coinfection in influenza

Morris DE, et al. Secondary bacterial infections associated with influenza pandemics. Front Microbiol. 2017 Jun 23;8:1041.

Lower and upper respiratory infections are the fourth highest cause of global mortality (Lozano et al., 2012). Epidemic and pandemic outbreaks of respiratory infection are a major medical concern, often causing considerable disease and a high death toll, typically over a relatively short period of time. Influenza is a major cause of epidemic and pandemic infection. Bacterial co/secondary infection further increases morbidity and mortality of influenza infection, with Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus reported as the most common causes. With increased antibiotic resistance and vaccine evasion it is important to monitor the epidemiology of pathogens in circulation to inform clinical treatment and development, particularly in the setting of an influenza epidemic/pandemic.

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Klein EY, et al. The frequency of influenza and bacterial coinfection: a systematic review and meta-analysis. Influenza Other Respir Viruses. 2016 Sep;10(5):394-403.

We found that bacterial coinfection of hospitalized patients with influenza is often common, although results were highly heterogeneous. The predominant coinfecting organism in the studies was S. pneumoniae followed by S. aureus, but many other organisms were also found to cause infections. Providers should consider possible bacterial coinfection in patients hospitalized with influenza, and bacterial cultures should be taken to avoid patient exposure to the risks of prolonged unnecessary antibiotic use. If antibiotic treatment is started, possible coinfection with MRSA should be considered, particularly for community‐acquired pneumonia infections, when selecting appropriate antibiotics, and therapy should be discontinued or de‐escalated as indicated by microbiological results. Finally, the frequency of coinfection should be better characterized in the entire influenza patient population, including outpatients, in future analyses.

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Nontypeable Haemophilus influenza infections

Langereis JD, de Jonge MI. Invasive Disease Caused by Nontypeable Haemophilus influenza. Emerg Infect Dis. 2015 Oct;21(10):1711-8.

The incidence of severe Haemophilus influenza infections, such as sepsis and meningitis, has declined substantially since the introduction of the H. influenzae serotype b vaccine. However, the H. influenzae type b vaccine fails to protect against nontypeable H. influenzae strains, which have become increasingly frequent causes of invasive disease, especially among children and the elderly. We summarize recent literature supporting the emergence of invasive nontypeable H. influenzae and describe mechanisms that may explain its increasing prevalence over the past 2 decades.

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Globus pharyngeus

Doody J, Fenton JE. Troublesome Throat Awareness (tTA) as a contemporary alternative to ‘globus pharyngeus’. Surgeon. 2017 Aug;15(4):183-185.

““Globus pharyngeus” is a tainted term suggesting that it is time to retire the title, as was done with “globus hystericus” two centuries ago. We suggest that the feeling of having a lump in the throat on dry swallow is a normal sensation that everyone experiences to some degree, is accentuated by an ‘event’ and perhaps some are predisposed to perceive this “regular” sensation more strongly than others. It is our opinion that an alternate and contemporary approach is required on this topic. We propose the new term of “troublesome Throat Awareness” (tTA) which is clear, unambiguous with an inherent and therefore therapeutic reassurance to the patient.”

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Jones D, Prowse S. Globus pharyngeus: an update for general practice. Br J Gen
Pract. 2015 Oct;65(639):554-5.

“Globus pharyngeus is a common condition frequently presenting to primary care. Its aetiology remains unclear; however, gastro-oesophageal reflux may play a role in a subset of patients. It is important to consider red flags and ensure prompt referral to secondary care if present.

Management of this condition includes reassurance, vocal hygiene, and treatment of reflux if this is appropriate. Speech and language therapy and cognitive behavioural therapy may also have a role.”

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Abdominal migraines

Irwin S, et al. Recurrent Gastrointestinal Disturbance: Abdominal Migraine and Cyclic Vomiting Syndrome. Curr Neurol Neurosci Rep. 2017 Mar;17(3):21.

Primary headache disorders, including migraine, are some of the most common neurological disorders presenting to hospital. Episodic syndromes that may be associated with migraine, including recurrent gastrointestinal disturbances such as abdominal migraine and cyclic vomiting, often pre-date or co-occur with the onset of migraine in a child who is at risk of developing the headache condition. The purpose of this review is to evaluate the two most common episodic syndromes, abdominal migraine and cyclic vomiting syndrome, including their pathophysiology, common presentations, and diagnostic criteria. Differential diagnosis and “red flag” features are outlined, and an approach to diagnostic work-up is offered. Finally, we provide an evidence-based review of management options and long-term prognosis. Future research should include randomized trials for the acute and preventive treatment of these disorders, as well as research as to whether early intervention can prevent progression to migraine and/or mitigate migraine severity.


Napthali K, et al. Abdominal migraine. Cephalalgia. 2016 Sep;36(10):980-6.

AM is relatively common, affecting up to 4% of the paediatric population. Whilst AM is not believed to continue into adulthood for the majority of children, it has the propensity to develop into probable migraine and recurrent abdominal pain in adulthood. The pathophysiology of this condition remains unclear and as a result treatment for this condition is suboptimal with avoidance of triggers and prophylactic treatment currently recommended when an episode begins.

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Unilateral hydronephrosis due to ureteropelvic junction obstruction

Weitz M, et al. Primary non-surgical management of unilateral ureteropelvic junction obstruction in children: a systematic review. Pediatr Nephrol. 2017 Dec;32(12):2203-2213.

Ureteropelvic junction obstruction (UPJO) is the most common obstructive uropathy and its optimal management remains controversial. However, there is a current trend towards non-surgical management. We aimed to determine the effects of the non-surgical management in children with unilateral UPJO. For a systematic review, we searched MEDLINE, EMBASE, CENTRAL, clinical trials registries, and selected conference proceedings for eligible studies. Any type of study reporting the outcomes renal function, secondary surgical intervention, drainage pattern or hydronephrosis of non-surgical management in children with unilateral UPJO was included. Data from 20 studies were extracted and evaluated by two independent authors. The pooled prevalence was 21% for split renal function deterioration, 27.9% for secondary surgical intervention, 3.2% for progressive hydronephrosis, and 82.2% for improved drainage pattern. Not all patients with surgical intervention regained split renal function from enrolment. Renal imaging methods did not strongly correlate with each other. Many studies had to be excluded because of a lack of detection of an obstruction or mixed populations with bilateral UPJO or other uropathies. The variable definitions of UPJO, different criteria for surgical intervention, incongruity of management protocols, and the imprecise reporting of outcomes were limiting factors in the comparability of the results, leading to heterogeneity in meta-analyses. Although the available evidence cannot recommend or refute the current non-surgical management, the systematic review clarifies aspects of the ongoing controversy by providing realistic estimates for non-surgical management in children with unilateral UPJO. Additionally, it reveals unclear potential risks, particularly for long-term outcomes, which were rarely reported.

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Toxic shock syndrome (focus on S. aureus infections)

Wilkins AL, et al. Toxic shock syndrome – the seven Rs of management and treatment. J Infect. 2017 Jun; 74 Suppl 1:S147-S152.

Staphylococcal and streptococcal toxic shock syndrome (TSS) are associated with significant morbidity and mortality. There has been considerable progress in understanding the pathophysiology and delineating optimal management and treatment. This article reviews the management of TSS, outlining the ‘Seven Rs of Managing and Treating TSS’: Recognition, Resuscitation, Removal of source of infection, Rational choice of antibiotics, Role of adjunctive treatment (clindamycin and intravenous immunoglobulin), Review of progress and Reduce risk of secondary cases in close contacts.

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Silversides JA, et al. Staphylococcal toxic shock syndrome: mechanisms and management. Curr Infect Dis Rep. 2010 Sep;12(5):392-400.

Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in which bacterial toxins act as superantigens, activating very large numbers of T cells and generating an overwhelming immune-mediated cytokine avalanche that manifests clinically as fever, rash, shock, and rapidly progressive multiple organ failure, often in young, previously healthy patients. The syndrome can occur with any site of S. aureus infection, and so clinicians of all medical specialties should have a firm grasp of the presentation and management. In this article, we review the literature on the pathophysiology, clinical features, and treatment of this serious condition with emphasis on recent insights into pathophysiology and on information of relevance to the practicing clinician.

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Fever of unknown origin (FUO) and fever without a source (FWS)

Definitions:

  • FUO – Children with fever >101ºF (38.3ºC) of at least eight days’ duration, in whom no diagnosis is apparent after initial outpatient or hospital evaluation that includes a careful history and physical examination and initial laboratory assessment.
  • FWS – Children with fever lasting for one week or less without adequate explanation after a careful history and thorough physical examination.

From UpToDate.


Antoon JW, et al. Pediatric fever of unknown origin. Pediatr Rev. 2015 Sep;36(9):380-90; quiz 391.

  • On the basis of strong clinical evidence, the causes of FUO are broad and include both benign and life-threatening medical conditions. (12)
  • On the basis of observational studies, most cases of FUO have shifted to noninfectious etiologies over the past several decades. (10)
  • On the basis of observational studies, completely normal physical examination findings at the time of the initial FUO evaluation suggest a benign underlying cause. (13)
  • On the basis of consensus and expert opinion, a stepwise, tiered approach to FUO should be implemented to decrease cost and time to diagnosis. (13)

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