Pediatric Primary Care Case Studies (80 page)

Unlike the child with a complicated presentation, the average toddler with apparent IDA (microcytic, hypochromic) needs no further testing before initiating therapy. A therapeutic trial of oral iron is usually adequate in high-risk populations as a diagnostic measure for presumptive iron deficiency anemia (Hermiston & Mentzer, 2002). Fer-in-sol is prescribed at 6 mg elemental iron/kg, divided into two or three doses a day. It is important to follow up with a reticulocyte count in 2–4 weeks. An elevated reticulocyte count indicates that iron is adequate to promote RBC growth and reticulocytosis has begun. During the initial
phase of therapy, the rate of RBC development is faster than normal and the reticulocytes are released early, with an extended lifespan of 2 days. Iron therapy needs to continue for 3–4 months to replenish the body’s iron stores. Poor response to iron therapy necessitates further laboratory work-up of the anemia.

What evaluation should be pursued for the child with severe anemia, atypical hematological findings, or a history suspicious for iron deficiency, or who does not respond to an initial trial of iron therapy?

Specific tests will be directed by the clinical presentation, history, and initial blood work. The causative factors of the anemia must be clarified. Information revealed in the complete blood count, peripheral blood smear, lead studies, thyroid studies, and hemoglobin electrophoresis would all help in refining the etiology of anemia. Findings in patient examination and history will further guide the diagnosis of anemia and the examinations needed to confirm the diagnosis. It is vital to remember that having the diagnosis of the type of anemia is not the end point. Anemia is a symptom of an underlying disorder. The anemia diagnosis narrows the diagnosis of the underlying disorder that needs further treatment.

Key Points from the Case

1. Assessing the child with anemia is a complex process that necessitates careful data gathering to determine the ultimate etiology. Providers need to walk a fine line between making too narrow and too wide a focus.

2. Integrate information from all available sources to help formulate the final diagnosis. All variables must be considered, with a focus on the incidence at the child’s stated age and health status. This necessitates a systematic and organized process of elimination.

3. A detailed history often reveals more useful data than the physical examination alone, so time is best spent obtaining as much relevant information as possible.

4. Keep in mind that the child is a product of his or her environment; explore environmental histories as a mainstay of healthcare visits.

REFERENCES

American Lung Association. (n.d.).
Pesticides
. Accessed November 9, 2008, from
http://www.lungusa.org/site/c.dvLUK9O0E/b.35384/k.F5CC/Pesticides.htm

Avery, M. (1994).
Pediatric medicine
. Baltimore: Williams & Wilkins.

Belson, M., Kingsley, B., & Holmes, A. (2007). Risk factors for acute leukemia in children: a review.
Environmental Health Perspectives, 115
(1), 138–145.

Berman, B. W. (2004). Pallor and anemia. In R. M. Kliegman, L. A. Greenbaum, & P. S. Lye (Eds.),
Practical strategies in pediatric diagnosis and therapy
(2nd ed., pp. 873–894). Philadelphia, PA: Saunders.

Borgna-Pignatti, C., & Marsella, M. (2008). Iron deficiency in infancy and childhood.
Pediatric Annals, 37
(5), 329–337.

Burchett, M. L., Hanna, C. E., & Steiner, R. D. (2009). Endocrine and metabolic diseases. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser (Eds.),
Pediatric primary care
(4th ed., pp. 584–611). St. Louis, MO: Saunders Elsevier.

Centers for Disease Control and Prevention. (2002). Iron deficiency—United States, 1999–2000.
Morbidity and Mortality Weekly Report
. Retrieved June 30, 2008, from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5140a1.htm

Centers for Disease Control and Prevention. (May 27, 2005). Blood lead levels—United States, 1999–2002.
Morbidity and Mortality Weekly Report, 54
(20), 513–516. Retrieved April 10, 2009, from
http://www.cdc.gov/mmwr/PDF/wk/mm5420.pdf

Cohen, M. (2007). Environmental toxins and health: the health impact of pesticides.
Australian Family Physician, 36
(12), 1002–1004.

Curl, C. L., Fenske, R. A., Kissel, J. C., Shirai, J. H., Moate, T. F., Griffith, W., et al. (2002). Evaluation of take-home organophosphorous pesticide exposure among agricultural workers and their children.
Environmental Health Perspectives, 110
(12), A787–A792.

Fenske, R. A., Chensheng, L., Curl, C. L., Shirai, J. H., & Kissel, J. C. (2005). Biologic monitoring to characterize organophosphorus pesticide exposure among children and workers: an analysis of recent studies in Washington state.
Environmental Health Perspectives, 113
(11), 1651–1657.

Gamis, A. S., Woods, W. G., Alonzo, T. A., Buxton, A., Lange, B., Barnard, D. R., et al. (2003). Increased age at diagnosis has a significantly negative effect on outcome in children with Down syndrome and acute myeloid leukemia: a report from the Children’s Cancer Group Study 2891.
Journal of Clinical Oncology, 21
(18), 3415–3422.

Garfunkel, L. C., Kaczorowski, J. M., & Christy, C. (2007).
Pediatric clinical advisor: instant diagnosis and treatment
(2nd ed.). Philadelphia: Mosby.

Hermiston, M. L., & Mentzer, W. C. (2002). A practical approach to the evaluation of the anemic child.
Pediatric Clinics of North America, 29
, 877–891.

Irwin, J. J., & Kirchner, J. T. (2001). Anemia in children.
American Family Physician, 64
(8), 1379–1386.

Karr, C. J., Solomon, G. M., & Brock-Utne, A. C. (2007). Health effects of common home, lawn, and garden pesticides.
Pediatric Clinical of North America, 54
, 63–80.

Kemp, C. (2005).
Mexicans and Mexican-Americans: health beliefs and practices
. Retrieved April 10, 2009, from
http://bearspace.baylor.edu/Charles_Kemp/www/hispanic_health.htm

Kliegman, R. M., Greenbaum, L. A., & Lye, P. S. (Eds.). (2004).
Practical strategies in pediatric diagnosis and therapy
(2nd ed). Philadelphia: Saunders.

Lambert, W. E., Lasarev, M., Muniz, J., Scherer, J., Rothlein, J. Santana, J., et al. (2005). Variation in organophosphate pesticide metabolites in urine of children living in agricultural communities.
Environmental Health Perspectives, 113
(4), 504–508.

Lee, M. T., & Truman, J. T. (2007). Anemia, acute.
eMedicine from WebMD
. Retrieved June 30, 2008, from
http://www.emedicine.com/ped/TOPIC98.HTM

Lesperance, L., Wu, A. C., & Bernstein, H. (2002). Putting a dent in iron deficiency.
Contemporary Pediatrics, 19
(7), 60–79.

Mullins, M. E., Brands, C. L., & Daya, M. R. (2000). Unintentional pediatric super-warfarin exposures: do we really need a prothrombin time?
Pediatrics, 105
(2), 402–404.

National Institutes of Health, Office of Dietary Supplements. (n.d.).
Dietary supplement fact sheet: iron
. Accessed December 22, 2008, from
http://ods.od.nih.gov/factsheets/iron.asp

Olson, K. R., Trickey, D. N., Miller, M. A., & Yungmann-Hile, L. (2008).
Toxicity, warfarin and superwarfarins
. Retrieved June 30, 2008, from
http://www.emedicine.com/emerg/topic872.htm

Paranzino, G. K., Butterfield, P., Nastoff, T., & Ranger, C. (2005). I PREPARE: developmental and clinical utility of an environmental exposures history mnemonic.
American Association of Occupational Health Nursing, 53
(1), 37–42.

Piomelli, S. (2002). Childhood lead poisoning.
Pediatric Clinics of North America, 49
, 1285–1304.

Roberts, J. R., & Reigart, J. R. (2002).
Managing elevated blood lead levels among young children: recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention
. Retrieved July 30, 2008, from
http://www.cdc.gov/nceh/lead/CaseManagement/chap3.pdf

Roberts, J. R., & Reigart, J. R. (2007). Managing elevated blood lead levels among young children: recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Retrieved July 30, 2008, from
http://www.cdc.gov/nceh/lead/CaseManagement/chap3.pdf

Robison, L. L., Nesbit, M. E. Jr, Sather, H. N., Level, C., Shahidi, N., Kennedy, A., et al. (1984). Down syndrome and acute leukemia in children: a 10-year retrospective survey from Children’s Cancer Study Group.
Journal of Pediatrics, 105
(2), 235–242.

Schwartz, M. K. (2009). Hematologic disorders. In: C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser (Eds.),
Pediatric primary care
(4th ed., pp. 612–633). St. Louis, MO: Saunders Elsevier.

Scott, J. P. (2006). Hematology. In: R. M. Kliegman, L. A. Greenbaum, & P. S. Lye (Eds.),
Practical strategies in pediatric diagnosis and therapy
(2nd ed., pp. 689–723). Philadelphia: Elsevier Saunders.

Shea, K. M. (n.d.).
Reducing low dose pesticide exposures in infants and children: a clinician’s guide from Physicians for Social Responsibility
[pamphlet]. Washington, DC: Physicians for Social Responsibility. Retrieved April 10, 2009, from
http://www.psr.org/site/DocServer/Reducing_Low-Dose_Pesticide_Exposures.pdf?docID=663

Spector, R. (1996).
Culture and diversity in health and illness
(4th ed.). Stamford, CT: Appleton & Lange.

Taketomo, C. K., Hodding, J. H., & Kraus, D. M. (2008).
Pediatric dosage handbook
(15th ed.). Hudson, Ohio: Lexi-comp.

Thompson, B., Coronado, G. D., Vigoren, E. M., Griffith, W. C., Fenske, R. A., Kissel, J. C., et al. (2008).
Para niños saludables:
a community intervention trial to reduce organophosphate pesticide exposure in children of farm-workers.
Environmental Health Perspectives, 116
(5), 687–694.

Tietz, N. W. (1995).
Clinical guidelines to laboratory tests
(3rd ed.). Philadelphia: W.B. Saunders.

U.S. Preventive Services Task Force. (2006).
Screening for Iron Deficiency Anemia
. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved April 2, 2009, from
http://www.ahrq.gov/clinic/uspstf/uspsiron.htm

Chapter 20

The Child with a Headache

Ritamarie John

Headache is a common problem in pediatric practice. Parents will bring children in for a headache complaint, concerned that their child has a brain tumor or infectious meningitis. The approach to the history and physical must be systematic and complete. Failing to do one part of the neurological exam can cause a delay in the correct diagnosis. In evaluating the chief complaint of headache, the provider needs to first determine whether the headache is a primary or secondary symptom.

Educational Objectives

1.   Apply evidence-based guidelines to classify the presenting complaint of headache.

2.   Apply shared decision making to develop the treatment plan.