Linda S. Nield

Prevention, Diagnosis, and Management of Diaper Dermatitis

pH of the skin that is associated with diaper wearing further activates the destructive enzymes. A child is at greatest risk of developing an irritant contact diaper rash in the first 2 years of life most likely because during these early childhood years, more time is spent in a diaper, less objection is raised by the child when soiling occurs and more frequent urinations and defecations occur daily. Any aged individual who requires the use of diapers on a long-term basis will develop some skin irritation at some point in time. The majority of newborns display mild diaper dermatitis by 1 week of age with increasing severity by age 3 weeks. Other irritants that promote skin breakdown in the perineum include glue used in diaper manufacturing 5 and friction produced by the diapers themselves or by the caregiver’s application of baby care products. A contact dermatitis due to chemical exposure of the buttock region after ingestion of a senna-containing laxative has also been reported.

Antibiotic lock solutions allow less systemic antibiotic exposure and less catheter malfunction without adversely affecting antimicrobial resistance patterns.

There are current concerns that antibiotic lock solutions (ABL) can induce antimicrobial resistance in long‐term hemodialysis patients. Retrospective chart review of 157 children on hemodialysis between January 1997 and June 2006 was performed. In ERA I, only systemic antibiotics were used. In ERA II, ABL were added to systemic antibiotics when needed. In ERA III, ABL were used for treatment of all cases of catheter‐related bacteremia (CRB) and for CRB prophylaxis in high‐risk patients. The study includes 111,325 catheter days. The CRB incidence was 3.9 CRB/1000 catheter days. There was significant decrease for the total systemic antibiotic exposure (P = 0.0484) and the percentage of catheters lost to malfunction (P = 0.001) in ERA III. Protocol ABL exposure was associated with a trend to increased tobramycin‐gentamicin resistance for gram‐positive CRBs (P = 0.2586) but with improved tobramycin‐gentamicin resistance for gram‐negative (P = 0.0949) and polymicrobial CRBs (P = 0.1776) and improved vancomycin resistance for gram‐positive CRBs (P = 0.0985). This retrospective analysis does not support the premise that ABL use will promote antimicrobial resistance in the hemodialysis population. The decreased exposure to systemic antibiotics by vigorous ABL use may even improve the antimicrobial resistance patterns in this population in the long term.

A novel CLCN5 mutation in a boy with asymptomatic proteinuria and focal global glomerulosclerosis.

Dent disease is an X-linked proximal tubulopathy that typically presents with hypercalciuria, low-molecular-weight proteinuria and slow progression to endstage renal disease. We report the case of a 5-year-old boy who presented with asymptomatic nephrotic range proteinuria and was later diagnosed with Dent disease. Absence of specific glomerular pathology in the first kidney biopsy led to erroneous treatment for presumably unsampled primary focal segmental glomerulosclerosis. Aggressive angiotensin blockade and immunosuppression resulted in significant side effects with marginal benefit. The continued nonspecific findings after a second kidney biopsy 2 years later led to the suspicion of a congenital tubulopathy. We detected a novel CLCN5 gene mutation, c.1396G > C, that creates a G466R missense change in the ClC-5 protein. Dent disease should be considered in the differential diagnosis of asymptomatic proteinuria for male patients. Profiling proteinuria in these patients by spot urine albumin/creatinine ratio may give the first clue to a tubulopathy. Determining the extent to which the clinical work-up should proceed for females with Dent phenotype or asymptomatic proteinuria remains to be a challenging clinical dilemma.

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,

Evaluation and management of illness in a child after international travel.

International travel by children is becoming increasingly common over the last few decades. As a result, clinicians may be asked to assist in the evaluation and treatment of an ill child after international travel. Along with recording the typical thorough history of present illness and medical history, the physician who cares for a child in this situation will have to take a thorough travel history and consider not only local conditions, but also possible pathogens that the child may have encountered during the journey. A detailed travel history should be routinely performed to investigate specific exposures. Reference materials are available that can guide the clinician in determining which infectious agents are endemic to various areas of the world. With the exception of obtaining a basic laboratory screen, further evaluation of the young patient should be dictated by the most likely cause of the illness. Repeated testing and examinations and close follow-up may be necessary to arrive at the proper diagnosis and initiate appropriate treatment in a timely manner.

Seizures in a 20-month-old native of minnesota : A case of neurocysticercosis

Abstract: A 20-month-old child, native of Minnesota, was diagnosed with neurocysticercosis. He had no history of international travel or pork consumption. This case and review of the literature emphasize the need to consider neurocysticercosis in any child with nonfebrile seizures in the United States because international travel and exposure to international travelers have become so common throughout the world.

Traumatized Twins: A Case Report and Discussion of the Maltreatment of Multiples

Child abuse is devastating to all involved, including the child, the parent, and the physician. It becomes doubly devastating when the victims are twins. There has been a great rise in the number of multiple births in the last two decades and therefore an increase in the stress that caregivers have to endure. Child abuse and neglect is more common in families with multiple births and mothers report that health professionals provide inadequate postpartum support and education with regards to parenting multiple newborns.1 In order to raise the clinician’s awareness of the increased risks associated with multiple births, we describe a case of traumatized twin boys and present a discussion of the maltreatment of multiples. Case Report

Alopecia in the General Pediatric Clinic: Who to Treat, Who to Refer

Although uncommon and typically benign, hair loss in children does occur and can be associated with serious illness. What is the pediatrician’s role in the evaluation and treatment of the child with alopecia? When should a dermatologist be consulted? A review of childhood alopecia is presented with emphasis on its most common causes. We also provide our recommendations concerning which children can be managed solely by the pediatrician and which ones should be referred to the dermatologist based on our clinical experience and review of the literature.

A Practical Approach to Precocious Puberty

her height is 123.5 cm. Breast development is now at Tanner Stage 3, pubic hair at Stage 2, and vaginal mucosa shows definite estrogen effect. At this followup visit, her growth velocity was determined to be 7 cm per year with a BA of 10 years. A pelvic ultrasound revealed normal ovaries with early pubertal size of the uterus, and results of other studies were as follows: LH, 8 IU/L (normal, 0.8-26 IU/L); FSH, 4.2 IU/L (normal, 1.4-9.6 IU/L); and estradiol, 48 pmol/mL (normal, 70-220 pmol/mL). A diagnosis of rapidly progressing precocious puberty was made and a GnRH stimulation test was done by the pediatric endocrinologist. LH and FSH levels increased to 24 IU/L and 22 IU/L, respectively, showing a pubertal response. A magnetic resonance imaging (MRI) of the brain was done, results of which were normal. She was diagnosed with idiopathic precocious puberty and started on leuprolide, a gonadotropin releasing hormone (GnRH) analog. At 6and 12-month follow-up, the FSH and LH response to GnRH stimulation is suppressed and growth rate has decreased appropriately.

Acute subdural hematoma: potential soccer injury in an otherwise healthy child.

A 16-year-old adolescent boy presented with headache, dizziness, loss of consciousness, and a tonic-clonic seizure after heading a soccer ball in a competitive match. A computed tomographic scan of the head revealed an acute subdural hematoma with a mass effect. The patient was emergently referred to a tertiary care facility where he eventually recovered completely with conservative care. No predisposing medical conditions were found. To the best of our knowledge, this is the first report of an intracranial hemorrhage secondary to the heading of a soccer ball alone in an otherwise healthy child without any underlying predisposing central nervous system abnormalities.