What Can I Do For Her Motion Sickness?

Patient Presentation
A 9-year-old female came to clinic for her health maintenance examination.
Her mother said that they would be travelling by airplane soon for a family vacation, and that in the past her daughter has had severe nausea with the airplane ride but no emesis, ataxia or headache.
The nausea resolved within a couple of hours, and the patient states that it is better if she can sleep. Her mother says that she looks pale during these episodes but does not sweat. The patient also says she is getting more nauseous during car rides since the family purchased a van.
She says it is is more difficult for her to look out the front window of the van. The patient does not have nausea with any other activities but she says she doesn’t like to go on the merry-go-round or swing on swings in general.
She has tried diphenhydramine (Benadryl®) in the past for long car trips which has helped her to sleep.
The past medical history, family history, and review of systems are normal.
The pertinent physical exam reveals a healthy female with normal growth parameters and neurological examination.
The diagnosis of motion sickness was made. The family was advised to try to position the patient in the car so she can look out the window into the distance. For long car rides and airplane rides, they were advised to try the diphenhydramine as it has been effective in the past. An alternative was to use dimenhydrinate (Dramamine®).
The physician also recommended that the patient try to avoid being too cold or hot as these could also irritate the patient and possible increase the nausea. Also small frequent amounts to eat such as nibbling on crackers could also possibly help.
Although the physician was unaware if they were effective in studies, he suggested trying ginger as this has been used by sailors for many years and also pressure point wrist bands that are put on acupuncture locations.

Discussion
Motion sickness is a common problem for many children. Young child often present with ataxia, but older children often have nausea and/or vomitting.
Additional symptoms include pallor, vertigo and sweats.

It is theoretically caused by problems integrating the body’s sensory systems, such as the visual and the vestibular pathways, which causes problems with the vestibular-cerebellar pathways and a resultant feeling of dizziness (i.e. lightheadedness), true vertigo (i.e. surrounding or self-spinning) and other symptoms as noted.

Learning Point
Treatment for motion sickness can be multifaceted.
Antihistamines such as dimenhydrinate can be helpful and work by preventing histamine response in sensory nerve endings and blood vessels. Another commonly used antihistamine is diphenhydramine. Meclizine (Antivert®) does not have a pediatric dosage for children under age 12 and is not recommended.

Anticholinergics work by central suppression of the vestibular-cerebellar pathways. Scopolamine is not recommended for children less than 12 years because of increased side effects and lack of clinical data.

Antidopaminergics are also not recommended because of the high incidence of extrapyramidal symptoms.

Studies have found that short-term use of ginger can be helpful for pregnancy-related nausea and emesis, but the studies are mixed on if it is helpful for nausea caused by motion sickness, surgery or chemotherapy.

How acupuncture or acupressure works is unknown but it may work by regulating the nervous system and neurochemistry, and therefore potentially could help with nausea. There is some data to support acupressure as an effective anti-nausea therapy.

Other treatments such as avoiding an activity (e.g. not riding on a merry-go-round), or trying to decrease the sensory input (e.g. sleeping through a car ride, or looking into the distance during a car ride to stabilize the visual input) may be helpful.

Questions for Further Discussion
1. What other complementary and alternative therapies are potentially beneficial for motion sickness?
2. How is migraine headache related to motion sickness?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MEDLINEplus for these topics: Motion Sickness and Alternative Medicine
and at Pediatric Common Questions, Quick Answers for this topic: Motion Sickness

To view current news articles on this topic check Google News.

National Center for Complementary and Alternative Medicine. Acupuncture. Available from the Internet at: http://nccam.nih.gov/health/acupuncture/ (rev. 12/2004, cited 7/13/06).

National Center for Complementary and Alternative Medicine. Ginger. Available from the Internet at: http://nccam.nih.gov/health/ginger/index.htm (rev. 5/2006, cited 7/13/06).

Friedman M, Hamid M. Dizziness, Vertigo and Imbalance. eMedicine.
Available from the Internet at http://www.emedicine.com/neuro/topic693.htm (rev. 5/30/2006, cited 7/13/2006).

Stauffer WM, Konop RJ, Kamat D. Traveling with Infants and Young Children Part I: Anticipatory Guidance: Travel Preparation and Preventive Health Advice. J. Travel Med, 2001;8:254-259.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice

    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    July 31, 2006

  • What Causes Priapsim?

    Patient Presentation
    A 11-year-old white male came to emergency room after he disclosed that he had had intermittent priapism for 3 days.
    Today, he has had continued priapism for several hours continuously. He denies trauma, medication or masturbation. He has not urinated for several hours.
    The past medical history was negative.
    The family history was positive for early cardiac disease.
    The review of systems was negative including fever, chills, night sweats, weight loss, or medication use. He says he noticed a rash on his body today, but no other bleeding.
    The pertinent physical exam showed a school age boy who was in distress secondary to pain. His vital signs showed a slightly elevated heart rate and blood pressure and growth parameters in the 25-75%.
    He had petechiae on his face, neck and trunk below the nipple line. He had two bruises on the shins which are healing. HEENT had slightly pale conjunctiva. His cardiac examination reveals tachycardia with a grade I-II systolic murmur best at the lower left sternal border.
    Lungs were negative but his abdomen had a liver edge that is 3 cm below the costal margin. The spleen was not palpable. Genitourinary examination revealed a circumcised male with bilateral testes in the scrotum. He has no pain on testicular examination and no inguinal hernia. He has an erect penis, that is swollen and deep red in color that is painful to examine.
    He had several 0.5-1.0 cm lymph nodes in the anterior cervical chain and in the inguinal area.
    The laboratory evaluation included a complete blood count which showed a hemoglobin of 8.0 mg/dl, platelets of 23 x 1000/mm2 and a white blood cell count of 78 x 1000/mm2 with almost all cells being small round blue cells, which were later confirmed to be blasts.
    The diagnosis of priapism secondary to new onset acute leukemia was made.
    The patient’s clinical course included being admitted to the intensive care unit where he received hydration, leukopheresis, and pain control.
    Aspiration of the corpus cavernosum with saline irrigation had minor relief of symptoms. Over the next 3 hours with leukophereis the patient had a decrease in the priapism and over the next 2 hours had resolution but some continued edema.
    He was transferred to the floor where he completed his initial evaluation for acute lymphocytic leukemia and began his induction chemotherapy. He stated that he had some erections since the priapism.

    Discussion
    Priapism is as unremitting, painful erection that is a true urological emergency.The corpora cavernosa engorgement causes compression of the venous outflow tracts, resulting in blood trapping within the corpora cavernosa. The corpora spongiosum and glans are not engorged.
    Priapism can occur in any age group, with peaks at age 5-10 years and 20-50 years.

    Low flow (ischemic) priapism is the most common type and is caused by an abnormal detumescence mechanism (the normal mechanism that release the venous blood ending an erection). This can be caused by excessive neurotransmitter release, blockage of the draining venules (as in sickle cell disease or leukemia), and changes in the smooth muscle of the corpora cavernosa.

    Prolonged low flow priapism causes an ischemia state leading to fibrosis of the corporeal smooth muscle and cavernosal artery thrombosis. Low flow priapism lasting more than 24 hours often leads to permanent impotence.
    If a malignancy is suspect then a pelvic computed tomographic scan may be indicated. Surgical treatment by shunting may be necessary if medical therapy similar to that which this patient received fails.

    High-flow priapism is caused most often becuase of blunt or penetrating trauma causing a fistula between the cavernosal artery and the corpus cavernosum with unchecked flow. Doppler ultrasound or pelvic angiography may be helpful for determining fistula location.

    Learning Point

    Causes of priapism include:

    • Sickle cell anemia – most common cause
    • Amyloidosis
    • Asplenia
    • Black widow spider venom
    • Carbon monoxide poisoning
    • Dialysis
    • Fabry disease
    • Fat emboli
    • Leukemia and other cancers
    • Medications – alcohol, cocaine, antihypertensive, psychotropics, anticoagulants, male and female hormones, metoclopramide, omeprazole, medications for erectile dysfunction
    • Malaria
    • Trauma – blunt and penetrating
    • Thalassemia
    • Spinal cord injury
    • Vasculitis

    Questions for Further Discussion
    1. What are other urological emergencies?
    2. What are presentations of acute leukemia?
    3. What are presentations of acute sickle cell anemia?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MEDLINEplus for this topic: Penis Disorders

    To view current news articles on this topic check Google News.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1740.

    Parraga-Marquez M. Wahlheim, Stantucci RA. Priapism. eMedicine. (rev. 11/14/2004, cited 6/9/06) Available from the Internet at: http://www.emedicine.com/med/topic1908.htm

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    July 17, 2006

  • Can I Use This Medicine When I am Breastfeeding?

    Patient Presentation
    A 24-year-old female came to clinic with her 1 month old healthy child. She had seasonal allergic rhinitis in the past and her symptoms that are now flaring up with itchy water eyes, itchy nose with clear rhinorrhea, and dark circles under her eyes.
    She previously took loratadine with good symptomatic relief, but she is breastfeeding and is worried about using it again.
    The past medical history reveals a normal, spontaneous vaginal birth with no complications pre- or post-natally.
    The pertinent physical exam shows a normal healthy infant.
    The diagnosis of a healthy infant with an appropriately-concerned breastfeeding mother was made.
    The physician checked the LactMed database from the National Library of Medicine whose summary stated: “Because of its lack of sedation and low milk levels, maternal use of loratadine would not be expected to cause any adverse effects in breastfed infants. Loratadine might have a negative effect on lactation, especially in combination with a sympathomimetic agent such as pseudoephedrine.”The mother was re-assured with the information, but was also told to monitor the infant and her milk supply and if there were changes to re-contact the physician.

    Discussion
    Breastfeeding provides the best possible food for an infant.
    Some advantages include providing good nutrition for the infant, low in cost, no preparation is needed and breastfeeding is instantly available.
    Breast feeding also helps mothers get back into overall physical shape and helps the uterus to tighten and return to normal size more quickly
    Breastfeeding may promote positive feelings towards the child and self.

    The disadvantages include that only the mother can breastfeed which takes time and energy and other family members may feel left out.

    There are a few medical reasons for not recommending breast-feeding such as when the mother is extremely ill and is unable to recover herself and breastfeed concurrently, or she needs to take
    certain medications that may pass into the milk and could be dangerous for the infant.
    Also if the mother has certain health conditions, such as Human Immunodeficiency Virus Syndrome (HIV), which could put her infant at risk, breastfeeding may not be advised.
    Note: The risk of acquired HIV through breastmilk is higher than the risk of infant morbidity and mortality in developed countries and breastfeeding is generally not recommended for women with HIV in developed countries.
    However, in underdeveloped countries the risk of acquired HIV through breast milk is lower than the general infant morbidity and mortality risk and therefore breastfeeding is generally promoted for women wth HIV in underdeveloped countries.

    Learning Point
    Drug information is one of the most common information needs of pediatricians and pediatric health care providers.
    Drug information for lactating women and its potential side-effects on the lactation process and the infant is often not readily available.
    The National Library of Medicine however publishes TOXNET Toxicology Data Network (http://www.toxnet.nlm.nih.gov/cgi-bin/sis/search)which includes 15 different databases that can be searched including information on hazardous materials and household products.
    It also includes LactMed Drug and Lactation Database (http://www.toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT) which is “A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider.”Drug name synonyms can also be searched concurrently (i.e. a search for the proprietary name of Claritin® will retrieve loratadine, the generic name)

    Questions for Further Discussion
    1. What environmental exposures should pregnant and lactating women be cautious of?
    2. What are some standards that can be used to help determine high-quality Internet information?
    3. What is the risk of an infant acquiring HIV from a mother who is breastfeeding?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MEDLINEplus for this topic: Breast Feeding

    and at Pediatric Common Questions, Quick Answers for this topic: Breastfeeding

    To view current news articles on this topic check Google News.

    Shelov SP, Hanneman RE. American Academy of Pediatrics Caring for Your Baby and Young Child Birth to Age 5. Bantam Books New York NY. 1993;68-69.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    July 11, 2006