key diagnoses in pediatrics - acdis

Key Diagnoses in Pediatrics

October 10, 2019

Objectives

At the completion of this educational activity, the learner will be able to:

• Explain how pediatric disease progression differs from adult progression

• Describe pediatric presentations of BPD, Dysphagia, Malnutrition, Septic

Shock and Heart Failure

• Begin to expand your CDI team’s scope of practice to pediatrics

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The patient is a 6 month old ex 28-week male with a history of a prolonged

NICU stay and ventilator use. He is now at home on 1/8 L/min O2 by nasal

cannula and takes a diuretic medication. He is followed by the Pulmonology

service as an outpatient.

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Bronchopulmonary Dysplasia (BPD)

What terms might you see?

• Ex-…weeker

• Former preemie

• Chronic lung disease

Why do providers use these terms?

• Unsure of exact criteria

• Assume the terms are interchangeable

• Patients are not babies anymore

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Severity-Based Definition of BPD

A premature infant (< 32 weeks’ gestational age) with BPD has persistent parenchymal lung disease,

radiographic confirmation of parenchymal lung disease and at 36 weeks post menstrual age (PMA)

requires 1 of the following FiO2 ranges/oxygen levels/O2 concentrations for ≥ 3 consecutive days to

maintain arterial oxygen concentration in the 90%-95% range:

Higgins RD, Jobe AH, Koso-Thomas M, Bancalari E, Viscardi RM, Hartert TV, et al. Bronchopulmonary Dysplasia:

Executive Summary of a Workshop. J Pediatr. 2018;197:300-308

Grade Invasive IPPV* CPAP, NIPPV, or

nasal cannula

≥3 L/min

Nasal cannula

flow of

1 - < 3 L/min

Hood

Oxygen

Nasal cannula

< 1 L/min

I --- 21% 22-29% 22-29% 22-70%

II 21% 22-29% ≥30% ≥30% >70%

III >21% ≥30%

Note: BPD Grade III (A) signifies early death (between 14 days of postnatal days and 36 weeks) owing to persistent

parenchymal lung disease and respiratory failure that cannot be attributable to other neonatal morbidities.

*Excluding infants ventilated for primary airway disease or central respiratory control conditions

Abbreviations: IPPV, intermittent positive pressure ventilation; NIPPV, noninvasive positive pressure ventilation

Consider the diagnosis of “BPD” when …

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Comorbidities Therapies Other clues

Extreme prematurity h/o mechanical ventilation Documentation of O2

toxicity

Low birth weight Home O2 Receives

Synagis/Palivizumab

Long NICU stay Chronic diuretics Increased risk of ICU care

& respiratory support with

colds

Other preemie dx: ROP,

NEC

Chronic inhaled steroid Acute on chronic resp

failure

Chronic visits to

pulmonology

New need for mechanical

ventilation

Chronic respiratory

“insufficiency”

documented

Dysphagia

The patient is a 9 mo female who was admitted with RSV bronchiolitis. She has

a history of recurrent respiratory infections, wheeze and coughing with

feedings. The patient was evaluated by the Feeding Team and was noted to

have mild to moderate laryngeal penetration with aspiration of thin liquids.

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Dysphagia


• Aspiration

• Oromotor dysfunction

• Feeding difficulties

• G-tube dependent

• Swallowing dysfunction


• The consequence may seem more important clinically than the

underlying cause

• Don’t think about the resource utilization

• May not know why patient has a G-tube

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Consider the diagnosis “dysphagia” when …

Comorbidities Symptoms Diagnosis Other clues

Spastic

quadriplegia

Coughing with

feeds

Feeding team

evaluation

Thickened feeds

Esophageal

atresia/TEF

Baby doesn’t suck

well

Videofluoroscopic

swallow study

(modified barium

swallow)

Recurrent

aspiration

pneumonia

Brain injury

Milk coming out

nose

Fiberoptic

endoscopic

evaluation of

swallow

NPO – gastrostomy

only

Craniofacial

malformations

Lips turn blue with

feeds

Robinul/

glycopyrrolate

Neuromuscular d/o Increased

secretions after

feeds

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Dysphagia: Adult and pediatric differences

Adult

Esophageal stricture 2°to GERD

or esophageal cancer

Achalasia

Scleroderma

Pill esophagitis

Stroke

Parkinson’s

ALS

Pediatric

Esophageal stricture 2°to caustic

ingestion or s/p EA repair

Vascular anomalies

Craniofacial malformations

Foreign body

Retropharyngeal abscess

SMA

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Malnutrition

The patient is a 17 year old male with CF and chronic sinusitis. He was recently

admitted for a CF pulmonary exacerbation. He was evaluated by the Nutrition

team and the consult note states the patient has a BMI z score of -3.2

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Malnutrition


• Failure to thrive (FTT)

• Poor weight gain

• Inappropriate weight loss

• Insufficient weight gain

• Poor growth


• FTT viewed as a broad term for the eval & treatment of poor weight gain

• Multiple definitions (i.e., WHO, ASPEN)

• Malnutrition may be viewed as a component of FTT, not other way

around

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Consider the diagnosis “malnutrition” when …Clinical

manifestations

Orders Etiology Caloric

supplementation

Decreased weight

gain velocity

TPN panel Failure to ingest

sufficient calories

Increased calorie

feeds

Decreased height

velocity

Re-feeding labs Increased metabolic

demands

NG feeds or G-tube

placement

Inadequate weight

for corrected age

Nutritionist consult Altered nutrient

absorption or

utilization

TPN

Inadequate weight

for height

Tube or central line

placement for

nutrition

Increased nutrient

losses Calorie counts

Inadequate BMI Speech consult Feeding team

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Malnutrition: Adult and pediatric differences

Adult

CHF – coronary artery disease

Depression

Malignancy

Social isolation

Dementia

COPD

Alcohol dependence

Hand tremors

Pediatric

CHF – congenital heart defect

Cystic fibrosis

Craniofacial malformations

Adenoidal hypertrophy

Child neglect

Genetic syndromes

Milk allergy

Intestinal tract obstruction

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Septic shock

The patient is a 4 year old female with acute lymphoblastic leukemia. She

recently completed a round of chemotherapy and has pancytopenia. The

patient presents to the ED with a fever and decreased urine output x 1 day. On

exam, she looks ill, is tachycardic and has a normal blood pressure. Skin is

cool and mottled with a cap refill of 3 seconds. Lactic acid is 3.7 mmol/L. Her

condition remains unchanged despite 60ml/kg IV fluid so an Epinephrine

infusion is started.

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Septic shock


• SIRS/sepsis physiology

• Sepsis with pressor requirement

• Poor perfusion

• Bacteremia


• Institutional culture

• Multiple definitions exist

• Don’t appreciate imprecise nature of language

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Septic shock resources

Adult

• Society of Critical Care Medicine/European Society of Intensive Care

Medicine 2016 guidelines

• Infectious Diseases Society of America does not endorse the

SCCM/ESICM 2016 guidelines

Pediatric

• Randolph, et al. International pediatric sepsis consensus conference:

definitions for sepsis and organ dysfunction in pediatrics. 2005

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Septic shock: Adult and pediatric differences

Adult

Hypotension is required

Pediatric

Hypotension is NOT required

Inadequate perfusion despite

adequate fluid resuscitation (≥40

mL/kg IV fluid)

Inadequate perfusion:

• Hypotension

• Vasoactive drugs to maintain

normal BP

OR

• 2 of the following: prolonged

capillary refill, oliguria,

metabolic acidosis/ elevated

arterial lactate

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Heart failure

The patient is a 3 month old male who was born with a complete AV canal,

large ASD, large VSD and severe common AVV regurgitation. Echocardiogram

with severe systolic biventricular dysfunction. The patient was treated with

Epinephrine and Milrinone. His lesions were not amenable to surgical repair

and he was ultimately listed for heart transplant given symptoms of

progressive heart failure.

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Heart failure


• Ventricular dysfunction

• Low cardiac output syndrome

• Cardiac insufficiency

• Excessive lung water

• Pulmonary over-circulation


• Don’t appreciate imprecise nature of language

• May not know the exact definitions

• Institutional culture

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Heart failure

Clinical

manifestations

Evaluation Etiology Therapies

Poor feeding PE - tachycardia, poor

perfusion, gallop,

tachypnea, wheezing,

hepatomegaly

Congenital defects Diuretics

Dyspnea and sweating

with feeds

CXR – cardiomegaly,

pulmonary edema

Cardiomyopathy Inotropes – Milrinone,

Epinephrine

Sleeping more than

normal

Echo – structural

defects, decreased

systolic function,

chamber enlargement

Myocarditis ACE inhibitors

Chronic

cough/wheeze

Labs – elevated BNP,

elevated lactate,

elevated troponin

Myocardial ischemia

(Kawasaki disease,

ALCAPA)

Other meds: β-

blockers anti-

arrythmics, digoxin

Abdominal pain, N/V Other - cardiac cath,

cardiac MRI, EKG,

exercise testing

Arrhythmias Mechanical circulatory

support - ECMO,

LVAD

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Heart failure: Adult and pediatric differences

Adult

Many cases due to ischemic

heart disease and hypertension

May present as exercise

intolerance, lightheadedness

Concomitant COPD

PediatricMany cases due to structural defect

May present as poor feeding/

malnutrition

Many cases of heart failure are

amenable to surgical repair - corrective

or palliative

Some CHF is not due to either systolic

or diastolic dysfunction

Echocardiogram can be difficult in non-

sedated babies

JVD not typically seen in infants/young

children

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Kids are not just little adults!

• Pediatric anatomy, physiology and pathology may differ from adults in

many ways

Kids are resilient and may not show signs of falling off the cliff until they

are already falling

Disease process and clinical presentation may be very different between

the two groups

• They may share the same diagnostic nomenclature

• There are less standard criteria and diagnostic definitions in pediatrics

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Pediatric Summary

Thank you to:

Daxa Clarke, MD

Lucinda Lo, MD

Sheilah Snyder, MD

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Questions?

[email protected]

[email protected]

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