Deepak Kamat

Upper Gastrointestinal Bleeding in Children

One of the initial considerations in managing a child with UGIB is to determine the extent and severity of bleeding. Many substances ingested by children may be mistaken for blood leading to a false diagnosis of UGIB. Red food coloring, fruit-flavored drinks, fruit juices, and beets may color the vomitus or stool reddish. Stools may also be of black color after ingestion of iron, grape juice, spinach, and blueberry. If diagnosis is suspect, stool should be tested by stool guaiac test and the vomitus or gastric aspirate should be tested by Gastroccult. In this test, alpha guaiaconic acid (active component of guaiac) reacts with hydrogen peroxide (active component of developer) in the presence of heme, which acts as a catalyst to produce a highly conjugated blue quinone compound. Many foods, such as undercooked meat, raw fruits, and vegetables, can cause false-positive occult blood testing especially in stool. Thus, a positive test result does not always indicate the presence of human blood.

Gynecomastia: Evaluation and Treatment Recommendations for Primary Care Providers

Gynecomastia is defined as excessive development of the breast in boys. It is common in neonates and adolescents. Although in most cases this is a transient phenomenon, it might lead to significant social impediments such as decreased participation in physical education because of embarrassment. A primary care provider should be able to diagnose a false gynecomastia, a physiologic gynecomastia, and a gynecomastia with underlying pathology by taking good history, performing a thorough physical examination, and checking few screening laboratory tests. In most cases with physiologic gynecomastia, just reassurance and close follow-up is sufficient; however, psychologic counseling and surgical intervention may be required in few selected cases of physiologic gynecomastia. Suspected cases with underlying pathologic causes should be referred to a pediatric endocrinologist for further evaluation and management. Treatment of underlying causes should resolve the gynecomastia in those patients.

DRESS Syndrome: A Practical Approach for Primary Care Practitioners

Drug rash with eosinophilia and systemic symptoms (DRESS), also called as drug hypersensitivity syndrome (DHS)/antiepileptic drug hypersensitivity syndrome, is a severe form of cutaneous drug reaction and is characterized by fever, skin rash, lymphadenopathy, hematological abnormalities, and internal organ involvement. In this case report, we present a child who developed DRESS with peripheral eosinophilia and hepatic involvement subsequent to the use of carbamazepine and who responded very well to systemic corticosteroids.

Music Therapy in Pediatrics

The soothing effects of music have been well described over the centuries and across cultures. In more recent times, studies have shown the beneficial effects of music in alleviating symptoms in a wide variety of clinical and psychologic conditions. Music therapy has been primarily used as an intervention to control emotional states, in pain management, cognitive processing, and stress management. Stress is associated with increased production of the stress hormone cortisol, which is known to suppress immune responses. Several studies in the past few decades have demonstrated a positive effect of music therapy on reducing stress or increasing immune responses, or both. Music therapy should therefore be considered as a valuable addition to standard pharmacologic therapeutic modalities in enhancing the immune response and lowering stress levels in such conditions. This article reviews the role of music as a therapeutic modality and the future for music therapy, particularly in pediatrics.

Evaluation of a Global Health Training Program for Pediatric Residents

Background: At Childrens Hospital of Michigan, an international health program was initiated in 2004. Objective: To evaluate the effectiveness of the program in imparting knowledge to pediatric residents. Design/Methods: A pretest examining international health knowledge was administered to pediatric residents, and they were reexamined at the end of 1 year. Results: Out of 20 residents who participated in the study, 11 (55%) fully participated in the international health program, and the other 9 partially participated. The mean overall pretest score was 56% and posttest score was 65.8% (P < .004). Full participant mean pretest was 57% and posttest was 69% (P < .005). Partial participant mean pretest was 55% and posttest was 62%, no significant difference (P = .10). Birth, medical education, residency training, or work history in a developing country did not impact pretest or posttest scores. Conclusions: Despite small numbers of participants, this evaluation suggests that knowledge in international health can be expanded through a training program.

Common Pediatric Dental Dilemmas

Tooth development begins as early as the sixth week of fetal life when a tooth bud forms from the primitive ectodermal-lined oral cavity. At about the fifth fetal month, dentinogenesis or the production of dentin begins. This lays the foundation for enamel formation, then calcification or hardening of the tooth occurs. Primary tooth formation, therefore, is an ongoing process from about the sixth week in utero through early childhood, until the root formation of the particular tooth is completed 2 to 3 years after the tooth erupts. Throughout this time frame, any oral or systemic health crises (ie, nutritional deficiencies, underlying syndromes, or systemic illness) in the fetus or the child may adversely affect tooth development. The first primary tooth typically erupts between 5 and 8 months postnatally. The mandibular central incisors usually erupt first, and by 30 months of age, the average child will have all 20 primary teeth in place. Eruption cysts, characterized as a bluish fluid-filled lesion around an erupting tooth, may appear a few weeks before the new tooth actually emerges. Usually asymptomatic, these cysts concern parents because of their appearance and the subsequent bleeding that occurs when the tooth breaks through the gingiva. The last primary teeth to erupt, between age 20 and 30 months, are the second maxillary and mandibular molars. Although almost all healthy children will experience the eruption of all of The American Academy of Pediatric Dentistry (AAPD) recommends that all children have an oral evaluation within 6 months of the eruption of the first tooth and have an established dental home by 1 year of age. The pediatrician has a crucial role in the establishment of a dental home as advocated by the American Academy of Pediatrics. A systematic literature review by Bader et al found that children referred to a dentist by a primary care provider were more likely to visit a dentist than children who were not referred. Although a pediatric dentist is the ideal resource for a parent who has a concern about their child’s teeth, the pediatrician is often the first medical professional contacted for dental advice. The pediatrician should have a basic knowledge about dental health because many general dentists are uncomfortable with caring for children in the first few years of life, and there are only about 4000 pediatric dentists in the United States. The appreciation of oral health as an integral part of the overall health of the child and the need for physicians to promote good oral health were core principles discussed at an international forum of dental experts in 2005. In addition to causing pain and cosmetic concerns, untreated dental abnormalities can lead to lifelong oral health problems. Dental issues that are often initially recognized or addressed in the general pediatric clinic are teething, delayed and ectopic dentition,

Erythrocyte Sedimentation Rate and C-Reactive Protein: How Best to Use Them in Clinical Practice

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are markers of inflammatory conditions and have been used extensively by clinicians both in outpatient and inpatient settings. It is important to understand the physiologic principles behind these two tests so clinicians may use them appropriately. For example, fibrinogen (for which ESR is an indirect measure) has a much longer half-life than CRP, making ESR helpful in monitoring chronic inflammatory conditions, whereas CRP is more useful in diagnosis as well as in monitoring responses to therapy in acute inflammatory conditions, such as acute infections. Many factors can result in falsely high or low ESR and CRP levels, and it is important to take note of these. Therefore, if used wisely, ESR and CRP can be complementary to good history taking and physical examination in the diagnosis and monitoring of inflammatory conditions.

Knowledge and Use of Music Therapy Among Pediatric Practitioners in Michigan

Objective Increasingly, music therapy is being used, in combination with conventional treatment modalities, as part of the health care treatment plan. The objective of our study was to determine the awareness, knowledge and use of music therapy by members of the Michigan chapter of the American Academy of Pediatrics (Michigan AAP) in their health care practice. Methods Members of the Michigan AAP were asked to participate in a survey designed to assess their knowledge and use of music therapy in their health care practice. Results Although the majority of respondents were aware of the use of music therapy in health care settings, very few had referred their own patients for music therapy services. Conclusion Music therapy is an inexpensive and noninvasive treatment modality being used increasingly, especially to alleviate pain, stress, and anxiety among patients in a variety of conditions. Pediatric practitioners in Michigan, who responded to our survey, expressed a strong interest in learning more about music therapy and learning about ways to incorporate music therapy into their health care practice.

Pediatric Hypertension: A Review for the Primary Care Provider

Hypertension affects nearly 50 million Americans and is associated with several diseases including atherosclerosis, coronary disease, diabetes mellitus, and end-stage renal disease (ESRD).1 Age-specific mortality is 30 times higher in children with ESRD than in children without it.2 Because hypertension contributes to ESRD, it is of great importance to identify and treat children with hypertension. Due to the significant effects of hypertension on several organs, adults in the United States are routinely screened for hypertension. The American Academy of Pediatrics recommends that this screening should be extended to the pediatric population in the United States, with annual blood pressure (BP) screening beginning with the child’s third birthday. However, despite these recommendations, in a study of 4 emergency departments, Silverman and colleagues reported that a significant percentage of pediatric patients did not have their BP checked.3 Although pediatric hypertension is rarely an emergency, it has been shown that childhood BP is the best predictor of adult BP.4 Pediatric hypertension is more common than is often perceived, with a prevalence rate of systolic hypertension in school-aged children of 1% to 5.8%.5-8 A positive family history of hypertension is an important risk factor for pediatric hypertension, because the incidence of hypertension in children of such families can be as high as 10%. Combined with the fact that children with HTN may have evidence of end-organ damage,9 it becomes of utmost importance to screen children early for hypertension. In this article, we review the literature on pediatric hypertension for more effective management in the care of children with hypertension.

Short stature in children: a practical approach for primary care providers.

Data gathered from population is used to define what is normal for age and gender. Terms such as “height below the 5th percentile” or “height 2 standard deviations below the mean (−2SDs)” are often used to define short stature. A more precise and medically correct definition is the “expected adult height,” which is calculated from parents’ heights. The height of a child should be evaluated in the light of his or her genetic potential. Most children achieve an adult stature within 10 cm of their genetic potential calculated from their parents’ heights. A child who is growing at a much lower percentile than for his or her genetic potential should have a thorough evaluation to exclude any underlying pathology that might explain this slow gain in height.