Tales from the ER Follow Up

Clinic

Tales from the ER Follow Up

Clinic

Dr. John MartinOctober 6, 2013Dr. John Martin

October 6, 2013

ER Follow Up ClinicER Follow Up Clinic

Review some common patients over the last 6 months

Talk about some common misconceptions about some of these cases

Look at some of the current evidence for treating these patients

BackgroundBackground

Developed in early 2000 by Dr. C. Enriquez (ER) and Dr. J. O’Dea (peds)

Identified need for specific patient group who needed quick follow up after being seen in the ER

Expanded to 2 clinics (Tuesdays and Fridays)

I became involve in March 2012

Case #1Case #16 week old presents with 2/7 history of diarrhea and rectal bleeding x 2 that day

Previously well

Feeding well -- very “spitty” after feeds for the last 3-4/52

Mom states baby has “projectile” vomiting at times

Formula fed

Case #1Case #1

Have switched formulas 5 times in the last 3 weeks on the advice of multiple sources

Rest of history unremarkable

Normal physical exam

Weight gain great - averaging 35 grams/day

Mother is +++ concerned baby is “allergic to formula”

Case #2Case #24 month old infant, breast fed for first 2.5 month

Mom starting introducing formula about 1 month ago

1-2 bottles per day

about 10 days ago - 8-10 episodes per day of bright green “mucousy” explosive diarrhea

Fine red rash between nipple line and distal femurs

Seen in ER -- treated for diaper dermatitis

F/U in 5/7 if no improvement

Return to exclusive breastfeeding during that time

Case #2Case #2Returned to ER 5/7 later -- no improvement in terms of diarrhea

Gassiness/Fussiness -- greatly improved. Rash gone

Diaper dermatitis -- resolved mostly

Good weight gain over 5/7

Stool samples -- C&S, viruses and C. Diff.

Switch to Alimentum / Eliminate cow’s milk completely from mom’s diet

Follow up in Resident’s clinic

Cow’s Milk Protein Allergy

Cow’s Milk Protein Allergy

Fairly uncommon entity (incidence estimated to be less than 3%)

Some (breast fed) population studies state it is as low as 0.15%

Symptoms may occur in up to 20% of the populations

Symptoms start within the first month of life, usually a week after the introduction of formula

Cow’s Milk Protein Allergy

Cow’s Milk Protein Allergy

Large differential

Anal fissures

Gastroenteritis

Diaper Dermatitis

Transient Cow’s Milk Intolerance

Cow’s Milk Protein Allergy

Cow’s Milk Protein Allergy

Two versions

Type I hypersensitivity - IgE mediated - significant effects

Urticaria, wheeze and vomitting present within hours of ingestions

Non-IgE mediated - present with similar features - usually at least 2 systems affected

50-60% Gastrointestinal symptoms (N/V/D/colic)

50-60% MSK features (atopic dermatitis, urticaria)

20-30% Respiratory symptoms (rhinoconjunctivist or wheeze)

Cow’s Milk Protein Allergy

Cow’s Milk Protein Allergy

To diagnose -- completely eliminate cow’s milk from diet

Formula fed infants - switch to a hydrolyzed formula

Breast Fed infants - completely eliminate cow’s milk from mother’s diet

After elimination period (~two weeks or more), reintroduce to see if symptoms return.

Lactose IntoleranceLactose IntoleranceAlways in the differential for “milk allergy”

Loose watery explosive diarrhea after the ingestion of cow’s milk (lactose)

Congenital Lactose Intolerance is extremely rare (case reports only)

Primary Intolerance - presents in infancy/childhood

Secondary Intolerance - follows a trigger (gastro, chemotherapy etc)

ManagementManagementIf it is a true CMPA -- eliminate cow’s milk from the diet

Breast Fed infants -- completely eliminate it from mother’s diet

Formula fed - switch to a hydrolyzed formula

Alimentum, Nutramigen, Neocate

No value in switching to soy

Cross-reactivity is described between 20-50%

ManagementManagement

Involvement of dieticians is very useful

Ensuring optimal nutrition of baby (and mother)

Re-introduction of cow’s milk after 1 year

~2/3 will tolerate reintroduction at 1 year

~85% will tolerate by 2 years

95%+ will tolerate by 3 years

Mother’s questionsMother’s questionsMy formula doesn’t have DHA/AA in it --- does that matter?

Omega-3 acids are felt to improve brain and eye development

Naturally occurring in breast milk

No evidence to suggest that adding these to formula has any benefit

Formulas with these additives cost more

Case #1Case #1By the time they were seen by me, diarrhea and bleeding had settled

Reflux was still an issue

Counselled about the importance of good feeding and burping techniques

Switch back to an iron-fortified formula

Followed up again after two weeks - reflux had mostly settled

Case #3Case #3

Seen in clinic 10/7 later

No change

Continues to have diarrhea (no blood)

Investigations are normal (BW done after clinic visit)

Cultures were negative

Case #3Case #34 week old infant -- referred for noisy breathing

Present basically since birth

Reassured by 5NB pediatrician, family doctor and public health nurse - baby is just a bit “mucousy”

“Gasping at times” - mother +++ worried that baby was going to stop breathing

Case #3Case #3

No cyanosis, no wheezing/grunting, no feeding issues

Birth history - remarkable

On exam - Beautiful “robust” baby

No distress - no accessory muscle use

Completely normal exam

Case #3Case #3

While talking to the parents after hearing the history/examining the patient

Baby is lying on the bed, 3/4’s asleep --- hear a very tiny squeak

Mother exclaims --- “That it!!!!”

LaryngomalaciaLaryngomalaciaMost common cause of stridor in infancy

Up to 75% of infants with stridor

Area of obstruction above the larynx

Presents in the first few weeks of life (usually by 4 months of age)

Can be worsened with feeding/crying/lying flat on back/sleep

Suck-Swallow-Breath reflex is a challenge in these infants

LaryngomalaciaLaryngomalaciaMultiple theories on why infants have this - anatomic abnormalities, cartilaginous variations and neurologic causes

Easy diagnosis -- perform flexible laryngoscopy in the office

40% of infants will be mild in nature

More severe case may need more aggressive management - feeding/weight gain may be significant issues

By 12-18 months symptoms will resolve

Case #3Case #3

Seen by ENT the next day

Performed flexible laryngoscope in clinic

Confirmed diagnosis of laryngomalacia

Clinic note - omega shaped epiglottis

Started on ranitidine suspension - 4mg/kg

Normal and Omega Shaped Epiglottis

Normal and Omega Shaped Epiglottis

Normal and Tubular Epiglottis

Normal and Tubular Epiglottis

Everyone of these patients come back on Ranitidine???Everyone of these patients come back on Ranitidine???

Clinically not suspicious of a diagnosis of reflux

ENT -- “There is some pretty good evidence for reflux in laryngomalacia”

What is the evidence for treating patients with laryngomalacia with anti-reflux medications??

Severe LM disease (??) seems to have best response to anti-reflux medications

RefluxRefluxFrom the perspective of a simple pediatrician:

All babies have GER (90%++ spit up)

GERD is a a concern in babies that have poor weight gain, refusal to feed, persistent crying

None of the medications we routinely use prevent reflux

Merely control acid secretion

AAP advocating for increasing lifestyle modifications before trials of medications

IJP --LaryngomalaciaIJP --LaryngomalaciaEstimated that 65-100% of babies with laryngomalacia have GERD as well

Acid reflux appears to have to have an “irritant” effect

Acid exposure within the larynx causes edema and further collapse of the laryngeal tissues

Recommend using ranitidine suspension 3mg/kg T.I.D. (9mg/kg/day)

Reflux dose in infants is 4-10mg/kg divided b.i.d. or t.i.d

Laryngomalacia and RefluxLaryngomalacia and RefluxOtolaryngology: H & N surgery, Hartl et al. 2012

Review of 27 studies (n=1295 infants) - ~60% had reflux based on varied definitions

Varied levels of evidence in the studies (no randomized control trials)

At best the authors could determine that there is a co-existence between acid reflux and laryngomalacia but evidence for a causal association is limited

Because there is widespread use of anti-reflux treatments, a RCT of anti-reflux vs. placebo is justified

Laryngomalacia and RefluxLaryngomalacia and Reflux

Arch Dis Child 2012 -- Apps et al.

Looked at the same question - does anti-reflux therapy improve symptoms in infants with LM??

Reviewed 13 case series - overall poor evidence for treating with anti-reflux medications (biased by patient selection, comparison groups and many subjective measures)

Case #3Case #3Follow up with me ~4 week after both visits

Parents think I’m a rocket scientist!!!!

Currently on ~5 mg/kg/day of ranitidine

Parents think this is what is making the difference

Increase the dose to 9mg/kg/day

Has done really well to date

Case #4Case #45 year old male

Brought to the ER with rash on legs and 2 episodes of “dark” urine

??? Blood

Complains of pain and swelling in feet/ankles - pain with walking and some pain in wrists

Episode of ?? strep throat 2/52 ago (Tx and well since)

HSP LesionsHSP Lesions

Case #4Case #4U/A confirmed microscopic hematuria - 30-50 RBC/hpf

1+ protein present as well (?? because of blood)

Told the diagnosis - discharged on Tylenol, F/U arranged in ER clinic

Mom went home and googled the diagnosis

Also talked to a cousin who is involved in dialysis

Mom drove into the ER at 1am “to see a specialist”

Case #4Case #4Symptoms subsided over the next week

Rash was getting a lot better

Admitted to hospital with an episode of “severe” abdominal pain

Settled spontaneously over 12 hours

Seen by rheumatology -- started on prednisone

Improved a lot at this point

Henoch-Schönlein PurpuraHenoch-Schönlein PurpuraNamed for two German physicians who described this in the late 19th century

Triad of purpura (rash), abdominal pain and arthritis

Small vessel vasculitis - precipitated typically by an infectious process (viral vs bacterial)

Medications can also cause this rxn (ceftriaxone, vancomycin, ranitidine etc.)

Immune mediated complexes found on vessel wall --IgA, C3

50% (range 20-70%) will have renal involvement

HSPHSPCan have some significant complications

GI bleeding

Intussuception

Renal involvement is also a major concern

Long term -- most children do very well

Over the 1st 6 months many will have relapses but progress to recovery - recurrent triggers

95% recover without complications (maybe even higher) - Renal involvement is the major concern

Is there value in treating with steroids first?

Is there value in treating with steroids first?

Steroids help minimize the symptoms of the initial presentation

Also help suppress the immune response

So why not treat all of these patients with prenisolone or prednisone on presentation

HSP and steroidsHSP and steroidsArc Dis Child - Dudley et al 2013

Large RCT of placebo vs prednisolone in presenting HSP patients

N = 350 -- Followed for 12 months

No differences in features of renal involvement between the two groups at the end of the study

?? Future studies to look at subgroups that might benefit from earlier steroids -- i.e. more severe cases

Case #4Case #4

Has done well since

Variable urinalysis - 2 episodes of microscopic hematuria, 2 normal ones

Mother still ++ anxious

Take home messagesTake home messages

Cow’s Milk Protein Allergy

Fairly rare condition (not as often we think or as often as the symptoms may suggest)

No need to change formulas frequently

If you do, use a hypoallergenic formula

Take Home MessageTake Home Message

Laryngomalacia

No real role for ranitidine in all patients -- may be a role in patients with severe disease

HSP

Common condition in childhood (especially with certain viral causes)

No proven role for treating all patients on presentation

Questions or Comments??Questions or Comments??