Clinical Pediatrics

Difficulty swallowing or dysphagia can be present in children and adults alike. Pediatric dysphagias have long been recognized in the literature. Certain groups of infants with specific developmental and/or medical conditions have been identified as being at high risk for developing dysphagia. Still others may present with a swallowing or feeding problem as their primary symptom. Left untreated, these problems in infants and children can lead to failure to thrive, aspiration pneumonias, gastroesophageal reflux, and/or the inability to establish and maintain proper nutrition and hydration. Awareness of the prevalence of pediatric dysphagia in today's population and the signs and symptoms of this condition aids in its treatment. Early detection of dysphagia in infants and children is important to prevent or minimize complications. This article provides a review of symptoms, etiologies, and resources available regarding management of this condition to help the primary care physician and the families of young children and infants in its management.

The objective of this study was to determine perceived benefits, detriments, and barriers to communication between pediatric providers and home visitors. The authors performed a cross-sectional, qualitative study consisting of 3 focus groups with paraprofessional home visitors (n = 12), 6 with parents receiving home visiting (n = 33), and 4 with pediatric providers whose patients received home visiting (n = 19). Emerging themes were generated by an inductive analytic approach. Perceived benefits included home visitors assisting parents with communication, giving providers family information, and reinforcing providers' guidance. Detriments included parental concern of sharing confidential information and providers becoming aware of family issues for which they are unprepared to act. Barriers included parental consent, logistics of home visitor—provider communication, and providers' lack of knowledge about home visitor programs/roles. Greater coordination between home visitation programs and pediatric providers may strengthen home visiting services and reinforce advice and anticipatory guidance given by providers.

Based on a retrospective 5-year medical record review, this study characterizes factors associated with patients discharged against medical advice (AMA) from a tertiary pediatric emergency department (ED) and compares rates of return to the ED and admission to the hospital with those of patients routinely discharged. Data from 94 patients discharged AMA are compared with those of 188 control patients. Pediatric patients at risk for discharge AMA are older than 15 years (odds ratio [OR], 3.561; 95% confidence interval [CI], 1.695-7.482), self-register independent of a parent (OR, 3.100; 95% CI, 1.818-152.770), arrive by ambulance (OR, 2.761; 95% CI, 1.267-6.018), involve a consultant (OR, 2.592; 95% CI, 1.507-4.458), and have a chief complaint of abdominal pain (OR, 3.095; 95% CI, 1.154-8.303). Negative predictors include urgent triage (OR, 0.155; 95% CI, 0.039-0.618), a chief complaint of upper respiratory tract illness or otitis media (OR, 0.229; 95% CI, 0.075-0.702), and discharge diagnoses of infection (adjusted OR, 0.053; 95% CI, 0.004-0.767), disease of the nervous system and sense organs (adjusted OR, 0.066; 95% CI, 0.005-0.898), respiratory illness (adjusted OR, 0.072; 95% CI, 0.007-0.718), and gastrointestinal disease (adjusted OR, 0.050; 95% CI, 0.006-0.419). Certain key elements of discharge AMA are well documented, including consequences of discharge AMA (74.5%) and instructions for care (54.3%). Other elements such as alternative therapies (1.1%) are poorly documented. Patients discharged AMA have a significantly higher return rate (24.5%) within 15 days compared with patients who have routine discharge (6.4%) (χ² = 18.85, P < .001). Ninety-six percent of patients who return to the ED have the same chief complaint at both visits if discharged AMA compared with 50% of patients who are discharged routinely (P = .003), with 25% admission rates at the time of second visit for both types of discharges. Adolescents who register themselves are at increased risk for discharge AMA. Patients who are triaged as urgent or nonurgent or who have minor illnesses are likely to be dispositioned routinely. Patients discharged AMA are more likely to return to the ED with the same complaint than patients who are routinely discharged.

This study evaluates the clinical profiles and outcomes of children with infantile-onset diabetes mellitus (IODM) (onset at <1 year). Twelve infants with IODM presenting to our hospital from January 2003 to December 2007 are analyzed. All undergo thorough history, clinical examination, and investigations and are managed as per hospital-approved protocol and periodically followed up. Of 12 infants (3 boys and 9 girls), 9 have a family history of DM. The median age at onset is 2.5 months. Six infants have features suggestive of Wolcott-Rallison syndrome (WRS), 4 infants have type 1 DM, and 1 infant each has Fanconi-Bickel syndrome and maturity-onset diabetes of young. None have pancreatic agenesis or calculi. Human leukocyte antigen (HLA) typing shows DQ3 and DR15 alleles predominating. Two children with WRS died; the rest are being followed up. The incidence of IODM is increasing, with multiple syndromic associations rather than a single perspective.

Objective The objective of this study was to describe and compare reading practices in caregivers of children with developmental/behavioral problems (DEV) to caregivers of children without developmental problems attending a general pediatric clinic (GEN).

Method Cross-sectional, convenience samples of 321 caregivers of DEV and GEN children self-report reading practices including amount of daytime and nighttime reading, TV viewing, and number of books in the house. Reading 4 or more days per week is the primary outcome. Multivariate logistic regression analysis was used to compare reading 4 or more days per week with specific predictors. Odds ratios and 95% confidence intervals were reported.

Results Three hundred and twenty-one caregivers participated in the study (DEV 204, GEN 117). Mean number of books in home (51.1 ± 49.9), TV viewing hours per day (2.6 ± 2.0), and days or nights read per week (days, 4.9 ± 2.1; nights, 4.0 ± 2.4) did not differ by group. Caregivers reporting incomes at 200% above the federal poverty level (FPL) were more likely to engage in reading more than 4 days per week (odds ratio 5.32; 95% confidence intervals, 1.19, 23.81) after controlling for developmental status, caregiver education and age, and frequency of television viewing.

Conclusion Positive home reading practices were predicted by FPL in children with and without developmental or behavioral problems and while controlling for child group status (DEV or GEN), caregiver education and age, and amount of TV viewing. Reading promotion programs should focus on children from low socioeconomic environments regardless of disability risk status.

This case discussion is part of the Integrating Basic Science Into Clinical Teaching Initiative. It examines the presentation of altered mental status and describes the underlying physiology, which explains the basic laboratory findings in an attempt to reach a diagnosis. This article describes a 13-year-old boy who presented to the emergency department with altered mental status after being found unconscious and alone in an abandoned building. He was unresponsive to painful and verbal stimuli, with otherwise normal findings on physical examination. Basic laboratory studies, including arterial blood gas, electrolytes, and serum osmolality, were obtained. The case discussion uses fundamentals of anatomy to build a focused differential diagnosis. The laboratory studies are interpreted using basic physiologic principles, including acid-base balance, anion gap, and osmolar gap, to determine the most likely cause of this patient's altered mental status. Subsequent investigation confirms a diagnosis of ethanol toxic effects. An understanding of electrolyte and acid-base physiology allows the clinician to use basic laboratory studies to build a focused differential diagnosis for altered mental status. This case discussion demonstrates how basic science principles of anatomy and physiology can be applied in clinical settings.

A low or normal white blood cell (WBC) count is usually associated with viral illnesses. This study evaluated the reliability of a new point-of-care, inexpensive, WBC count device which requires only 10 µL (1 drop) of whole blood from a finger stick to an automated Cell-Dyn® counter in a busy office practice setting and assessed its reliability to assist in avoiding antibiotic prescribing. A total of 120 acutely ill children and potential antibiotic recipients were studied from October 2007 to March 2008. The mean WBC count was 7.4 × 10⁹/L and 8.1 × 10 ⁹/L for the new WBC device and the automated Cell-Dyn counter, respectively. The correlation between the 2 devices was high (r = .988, P = .005). A total of 88 children (73%) did not receive antibiotics and mean WBC was 7.2 × 10⁹/L. In all, 32 children (27%) received an antibiotic and 1 (3%) returned for a follow-up office visit for the same or a related illness. Of the 88 children with a low blood count who did not receive an antibiotic, 3 (3%) had return visit within 30 days and received an antibiotic. A simple and quick point-of-care WBC count device produces similar results as achievable with a Cell-Dyn counter for total WBCs and may assist in judicious antibiotic prescribing.

The objective was to determine the prevalence of therapies used by parents to manage acute diarrhea in their children and determine extent of parental adherence to current management guidelines and utilization of functional foods. Parents (N = 623) of children with diarrhea were surveyed in a tertiary care pediatric emergency department. Most (53%) treated their child's diarrhea with appropriate fluids, including oral rehydration solution (52%), but 14% used treatments not recommended in current guidelines (antidiarrheals, 8%; fluids high in simple sugars, 6%). In addition, 13% used functional foods (yogurt, 11%; probiotics, 4%). Children whose parents did not adhere to guidelines were older (OR 1.02; 95% CI 1.01-1.02 years) and Hispanic (OR 2.1; 95% CI 1.1-3.9). Although most parents use appropriate fluids to treat their children's diarrhea, functional foods and antidiarrheal medications were also frequently administered. Further data on effectiveness of functional foods and education regarding avoidance of potentially harmful medications are needed.

Prior research has demonstrated that limited English proficiency in Hispanic patients is associated with adverse health outcomes. The authors sought to compare the perception of primary care in resident practices between Spanish-speaking and English-speaking parents using a previously validated tool, the Parents' Perception of Primary Care. Using survey results from 19 CORNET sites nationwide, they compared mean scores for each primary care domain and the full scale between the groups using Student's t test. Multiple linear regression models compared outcomes controlling for demographic variables. Of the 2122 analyzable surveys, 490 (23%) were completed in Spanish and 1632 (77%) in English. The mean scores for each domain and the total scale were not statistically different between the 2 groups. After adjustment, Spanish-speaking parents rated communication significantly higher. Resident clinics may use systems to provide high quality care to Spanish-speaking patients, which may help other sites improve care.

Mycoplasma pneumoniae is an important causative agent of respiratory infection in childhood. Although the infection caused by M. pneumoniae is classically described as benign, severe and life-threatening pulmonary and extrapulmonary complications can occur. This study describes the first case of septic shock related to M. pneumoniae in a child with necrotizing pneumonitis, severe encephalitis, and multiple organs involvement, with a favorable outcome after lobectomy and systemic corticosteroids

Acute hemorrhagic edema of infancy (AHEI) is a cutaneous leukocytoclastic vasculitis that usually occurs in children younger than 2 years of age. It is a rare disease characterized by mild fever, a violent onset of hemorrhagic skin lesions, and edema usually followed by a spontaneous and complete recovery. Although the etiology is unknown, AHEI often follows infections, drug treatment, or vaccination. In the present report, the authors describe 4 cases of AHEI and review the relevant literature.