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Tales from the ER Follow Up Clinic

Tales from the ER Follow Up Clinic. Dr. John Martin October 6, 2013. ER 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. Background.

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Tales from the ER Follow Up Clinic

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  1. Tales from the ER Follow Up Clinic • Dr. John Martin • October 6, 2013

  2. ER 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

  3. Background • 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

  4. Case #1 • 6 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

  5. Case #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”

  6. Case #2 • 4 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

  7. Case #2 • Returned 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

  8. 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

  9. Cow’s Milk Protein Allergy • Large differential • Anal fissures • Gastroenteritis • Diaper Dermatitis • Transient Cow’s Milk Intolerance

  10. 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)

  11. 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.

  12. Lactose Intolerance • Always 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)

  13. Management • If 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%

  14. Management • 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

  15. Mother’s questions • My 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

  16. Case #1 • By 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

  17. Case #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

  18. Case #3 • 4 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

  19. Case #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

  20. Case #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!!!!”

  21. Laryngomalacia • Most 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

  22. Laryngomalacia • Multiple 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

  23. Case #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

  24. Normal and Omega Shaped Epiglottis

  25. Normal and Tubular Epiglottis

  26. 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

  27. Reflux • From 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

  28. IJP --Laryngomalacia • Estimated 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

  29. Laryngomalacia and Reflux • Otolaryngology: 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

  30. Laryngomalacia 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)

  31. Case #3 • Follow 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

  32. Case #4 • 5 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)

  33. HSP Lesions

  34. Case #4 • U/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”

  35. Case #4 • Symptoms 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

  36. Henoch-Schönlein Purpura • Named 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

  37. HSP • Can 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

  38. 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

  39. HSP and steroids • Arc 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

  40. Case #4 • Has done well since • Variable urinalysis - 2 episodes of microscopic hematuria, 2 normal ones • Mother still ++ anxious

  41. Take 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

  42. Take 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

  43. Questions or Comments??

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