Pediatric Primary Care Case Studies (98 page)

Tell Mrs. Smith to call and ask for a same-day appointment if Mary is not better in 48 hours or to return sooner (or at any time) if her symptoms worsen. It is important to provide an immediate recheck if there is no improvement within 48 hours because this generally indicates the need to rethink the diagnosis and management plan. If her condition has worsened at follow-up, she should be evaluated for potential complications and the need for a chest X-ray, complete blood count, and/or hospitalization. If improved, schedule a recheck at the completion of antibiotic therapy.

Is this child infectious to others and what is the typical progression of recovery?

Transmission of
Mycoplasma pneumoniae
is by person-to-person contact with respiratory secretion. Its incubation period is 1 to 4 weeks. Typically, within 24 to 48 hours of antibiotic coverage the child will no longer be considered contagious (Centers for Disease Control and Prevention, 2005).

Overall outcomes in children with pneumonia are excellent. A change in respiratory sounds is typically noted by the second or third day with consolidation
of the infection. Resolution occurs around the seventh day (Brady, 2009). The majority of children recover without complications. Radiographs may be abnormal for 6 weeks; therefore, serial X-rays are not recommended in uncomplicated pneumonia (Durbin & Stille, 2008). Follow-up radiographs 2 to 3 weeks after completion of therapy may be helpful in assessing alternate diagnoses or coincident conditions in children with recurrent pneumonia, persistent symptoms, severe atelectasis, or unusually located infiltrates.

Key Points from this Case

1. A macrolide is the drug of choice for the treatment of
Mycoplasma pneumoniae.

2. The decision to hospitalize a child with pneumonia must be individualized and is based on age, underlying conditions, and severity of illness.

3. Children who are treated for pneumonia as outpatients should have follow-up within 24 hours. Those whose complications have worsened at follow-up should be evaluated for potential complications and hospitalization.

REFERENCES

Brady, M. A. (2009). Respiratory disorders. In: C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser (Eds.),
Pediatric primary care
(4th ed., pp. 767–794). St. Louis, MO: Saunders Elsevier.

Centers for Disease Control and Prevention. (2005).
Mycoplasma pneumoniae.
Retrieved May 11, 2009, from
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/mycoplasmapneum_t.htm

Durbin, J. W., & Stille, C. (2008). Pneumonia.
Pediatrics in Review, 2
, 147–160.

Gaston, B. (2002). Pneumonia.
Pediatrics in Review, 23
, 132–140.

Jenson, H. B. & Baltimore, H. J. (2006). Pneumonia. In: R. M. Kliegan, K. J. Marcdante, H. B. Jenson, R. E. Behrman (Eds.),
Nelson essentials of pediatrics
(5th ed., pp. 503–509). Philadelphia: Elsevier Saunders.

Nohynek, H., Valkeila, E., Leinonen, M., & Eskola, J. (1995). Erythrocyte sedimentation rate, white blood cell count and serum C-reactive protein in assessing etiologic diagnosis of acute lower respiratory infections in children.
Pediatric
Infectious Disease Journal, 14(6)
, 484–490.

Pickering, L. K., Baker, C. J., Long, S. S., & McMillan, J. A. (Eds.). (2006).
Red book:
2006 report of the Committee on Infectious Diseases
(27th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Rudan, I., Tomaskovic, L., Boschi-Pinto, C., & Campbell, H. (2004). Global estimate of the incidence of clinical pneumonia among children under five years of age.
Bulletin of the World Health Organization, 82
, 895–903.

Chapter 25

The Child with Vomiting and Diarrhea

Ardys M. Dunn
Victoria Winter

Vomiting and diarrhea are common phenomena in children. They often occur simultaneously, especially in the young child, and are most often associated with gastroenteritis. This case study focuses on the question of when the child with diarrhea can be managed with a telephone consultation and when he or she needs to be seen by the healthcare provider. In answering this question, we will examine the presentation of gastroenteritis in children, its epidemiology, etiology, differential diagnosis, diagnostic criteria, and treatment.

A case of gastroenteritis can be short-lived and managed with minimal intervention, or it can be the initial manifestation of a wide spectrum of acute and chronic disorders requiring more intensive therapy. The history and physical examination are essential for accurate assessment and diagnosis, and in conjunction with occasional laboratory tests, should guide care. Patient and family education on preventive measures can be effective in limiting the number of episodes of gastroenteritis in the home and the community.

Educational Objectives

1.    Identify the major etiologies of gastroenteritis in the United States.

2.    Explain the pathophysiology of the different types of diarrhea.

3.    State the factors that place the child at increased risk for hospitalization or death due to diarrhea.

4.    Determine when a healthcare provider can use telephone assessment versus inperson office assessment of the child.

5.    Describe treatment plans for acute, self-limited gastroenteritis and for severe gastroenteritis with dehydration.

   Case Presentation and Discussion

Sara’s mother is on the phone, calling about her 4-year-old daughter, who is sick with vomiting and diarrhea. “I feel ridiculous calling again, but Sara is sick. She started out with vomiting and then diarrhea, and now she is running a fever. I’ve tried everything I can think of to keep her well but this is the third time this year she has been sick. I think I need to
bring her into the office. Do you think there is something seriously wrong with her that is causing all of this?”

Your office assistant informs you about this phone call. She asks what you want her to tell Sara’s mother. Do you want her to bring Sara into the office? Or is this something that can be handled on the phone?

Before you answer, the following provides some important information about gastroenteritis.

Epidemiology of Gastroenteritis

Diarrhea results in over 1 billion episodes of illness and 3–5 million deaths annually worldwide, placing it with upper respiratory tract infections as the most common infectious disease syndromes of humans. In the United States, gastroenteritis is a leading cause of morbidity and the second most common disease seen in children (Jenson & Baltimore, 2006; Lopez, Mathers, Ezzati, Jamison, & Murray, 2006; Pickering & Snyder, 2004). Most cases in this country are self-limited and require only minimal intervention aimed at dietary and fluid management. However, occasional episodes of severe, life-threatening gastroenteritis may occur, necessitating aggressive therapeutic intervention.

By definition, acute gastroenteritis is an illness of rapid onset that includes diarrhea with possible nausea, vomiting, lethargy, fever, abdominal pain, or dehydration (common in young children). Liquidity and frequency of stool are characteristic features (Jenson & Baltimore, 2006; Pickering & Snyder, 2004). Caring for a child with gastroenteritis can present a challenge to parents who must make judgments about how to keep their child hydrated during this illness, when to call or have their child seen by the pediatric primary care provider, and how to prevent this illness from occurring again or spreading to other members of the family or close contacts of the child.

Etiology of Gastroenteritis

The most common causative agents of gastroenteritis in the United States include (Pickering, Baker, Long, & McMillan, 2006):

•   
Viral agents:
Rotavirus, adenovirus, Norwalk, and calicivirus

•   
Bacterial agents:
Shigella, Salmonella, and
Campylobacter jejuni

•   
Parasitic agents: Giardia lamblia, Entamoeba histolytica
, and Cryptosporidium

•   
Agents that produce enterotoxins: S. aureus, E. coli
(0157:H7), and
C. difficile

Acute viral infectious gastroenteritis accounts for 70–80% of the cases of diarrhea in developed countries and results in more than 1.5 million outpatient visits and 200,000 hospitalizations in the United States each year (King, Glass, Bresee, Duggan, & Centers for Disease Control and Prevention, 2003).

Diarrhea in children can also be due to a systemic, nongastrointestinal infection; antibiotics; feeding patterns; and enzyme deficiency.

Important studies on the etiology of gastroenteritis reveal the following pattern:

•   A common disorder seen in the pediatric population in the emergency department (ED) is viral gastroenteritis. Rotavirus and norovirus play key roles in such viral illnesses. It is estimated that four out of five children in the United States will develop a symptomatic rotavirus gastroenteritis by age 5 years. One in seven will be seen in an ambulatory health setting, with an additional 205,000 to 272,000 ED visits due to this virus (Payne, Stockman, Gentsch, & Parashar, 2008). It is estimated that the noroviruses may be responsible for more than 235,000 clinic visits and 91,000 ED visits in children under 5 years of age living in the United States (Patel et al., 2008). With the use of the rotavirus vaccine, their numbers should decrease.

•   Extra-intestinal infections, such as otitis media, urinary tract infections, and pneumonia, can cause acute diarrhea that is mild and self-limited in nature (Berkun et al., 2008; Defilippi et al., 2008).

•   Antibiotic-associated diarrhea (AAD) occurs commonly (Turck et al., 2003) and is thought to be associated with a disruption in normal flora (Surawicz, 2003).

•   Overfeeding, especially with hyperosmolar fluids (i.e., soft drinks, apple juice, and broth) can cause diarrhea (Dennison, 1996). Limiting intake of solid foods can cause a thin, watery, green stool.

•   Lactase deficiency in the form of hypolactasia or lactase nonpersistence can cause diarrhea (Heyman & AAP Committee on Nutrition, 2006).

Pathophysiology of Vomiting and Diarrhea

Vomiting is the forceful expulsion of stomach (and sometimes duodenal) contents, often preceded by nausea. It should not be confused with regurgitation, which is the flow of undigested material from the lower esophagus and stomach without the associated forceful muscle contractions. Vomiting is a function of neuronal activity in the brainstem, specifically in the medulla oblongata of the hindbrain. The hypothalamus, stimulated by the same neuronal activity, also plays a role in vomiting. Two dynamics appear to occur leading to vomiting seen in conjunction with diarrhea: Chemosensitive receptors detect emetic agents in the bloodstream and transmit a message to the nucleus tractus solitarius (NTS) in the medulla, and vagal afferent nerves detect changes in intestinal contents and tone and send messages to the same site. The NTS is a complex of subnucleii related to gastric, laryngeal, and pharyngeal sensation; swallowing; baroreceptor function; and respiration. Neurostimulation of this center leads to the autonomic changes seen in vomiting (Hornby, 2001).

Vomiting with secretory and cytotoxic diarrhea may be due to a functional ileus seen in these conditions. As a result of the decreased intestinal tone and slowed peristalsis of a functional ileus, the intestinal lumen dilates causing abdominal pain and vomiting; gastric emptying is delayed, causing vomiting; and the patient experiences cramping due to peristaltic rushes.

Common causative factors for vomiting in infancy that are included in a differential diagnosis are congenital obstructive lesions (neonatal period), allergic reactions to formula (the first 2 months of life), pyloric stenosis, and metabolic disorders. For older children, viral or bacterial gastroenteritis or food poisoning are the more common causes of vomiting. Urinary tract infections, streptococcal pharyngitis, and otitis also are associated with vomiting. Central nervous system problems, migraine headaches, and other gastrointestinal anomalies must also be considered (Bishop, 2006).