Does Silicone Gel Sheeting Work?

Patient Presentation
A 2-year-old African-American female came to clinic for suture removal 8 days after being cut by a metal edge on her forearm. The pertinent physical exam showed a 2 cm scar that was well healed with no surrounding erythema or tenderness. The diagnosis of healing laceration was made and the sutures were removed. The mother asked about ways to minimize the scarring as she herself had several hypertrophic and keloid scars. She had used different vitamin creams with mixed results and wondered if using silicone sheeting may help. The physician was not sure about it but said she would check and call the family. A PUBMED search found several articles that showed efficacy but that the sheets had to be used for many hours a day and for several weeks to months. She discussed this with the mother who wanted to try using them. The pediatrician cautioned the mother to wait until at least 2 weeks after the injury to begin using them. She also cautioned to try to keep the child from pulling off the sheets and possibly ingesting them. She recommended long-sleeved clothing to minimize this risk and to keep the sheets in place. The patient’s clinical course at her next health supervision examination showed a well-healed minimal scar that was hypopigmented. The pediatrician reminded the mother that hypopigmentation was a common problem with wounds but that the coloring would become more uniform usually over 6-12 months.

Discussion
There are 3 phases of wound healing:

  • Inflammation – the damaged vessels produce exudate to fill the wound
  • Granulation – epithelization, re-creation of the blood vessels and reinforcing of the injured area
  • Remodeling – fibroblast proliferation with deposition of collagen and remodeling of the area. This can last up to 2 years later.

Hypertrophic scars have an increased amount of scar tissue within the original wound boundary, whereas keloids have tissue that extends beyond the borders.

A recent review article graded the overall efficacy various of topical scar therapies. Silicone gel sheeting had “marked benefit” while pressure therapy (use of custom fitted pressure garments) and Imiquimod cream had “some benefit.” Polyurethane dressings and topical Vitamin A had “equivocal results”, and onion extract and topical Vitamin E had “no adequate benefit.” The Cochrane Collaboration Intervention Review in 2007 concluded that “…[T]rials…are of poor quality and highly susceptible to bias. There is weak evidence of a benefit of silicone gel sheeting as a prevention for abnormal scarring in high risk individuals but the poor quality of research means a great deal of uncertainty prevails.”

Learning Point
Silicone gel sheeting was introduced almost 30 years ago. While it’s mechanism of action remains unclear, postulated effects include increasing temperature, pressure, oxygen tension, hydration and the silicone itself. Some of the data is inconsistent but has shown increased or no change in temperature or pressure around the wound. Silicone sheeting is permeable, thus allowing more oxygen to seep into the hydrated skin and thus improve wound healing. Hydration itself is hypothesized to decrease capillary activity. Data supports silicone sheeting working better than silicone gel or oil by themselves which is consistent with studies showing silicone permeates only slightly into the stratum corneum. Overall it appears that occlusion of the scar and subsequent hydration decreases “…capillary activity, thereby reducing fibroblast-induced collagen deposition and scar hypertrophy.” Hyperremia would thereby be reduced resulting in less wound redness and with less resulting collagen deposition, the scars are flatter.

Looking at the whole, silicone sheeting appears effective for prevention and treatment of hypertrophic scar and/or keloid formation. Most treatment requires wearing the sheeting 12-24 hours/day for at least 2-3 months. Clinical trials vary depending on the wound/scar studied, site and especially treatment length. Studies of new scars appear to show efficacy with shorter treatment periods (2-4 months of treatment with various amounts of followup time) but treatment of old scars may show some efficacy too after longer time periods of treatment.

Silicone sheeting is relatively low cost and easy to use. Silicone sheeting should not be used on unhealed or open wounds. The sheeting is reusable and should be washed with soap and water and dried between uses (at least daily) and needs to be replaced when it begins to disintegrate. Side effects are usually minimal and usually related to hygiene of the underlying skin or irritation of the skin from the product itself. Improving hygiene, changing products, and/or gradually increasing the amount of time using the product can reduce the side effects. The sheeting comes in a variety of forms including self-adhesive or non-adhesive. Some non-adhesive products can have tape applied directly to the sheeting and other products require a seperate bandage over the sheeting to secure it. Therefore some products may be difficult to use. It can be difficult to use the products in areas of movement (e.g. elbows, wrists, etc.).

Questions for Further Discussion
1. What are possible treatments for keloid scars?
2. What are indications for scar revisions?

Related Cases

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

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Wounds

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

To view images related to this topic check Google Images.

Zurada JM, Kriegel D, Davis IC. Topical treatments for hypertrophic scars. J Am Acad Dermatol. 2006 Dec;55(6):1024-31.

Berman B, Perez OA, Konda S, Kohut BE, Viera MH, Delgado S, Zell D, Li Q. A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management. Dermatol Surg. 2007 Nov;33(11):1291-302;1302-3.

O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003826.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    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.

  • 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.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

    Author

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

  • "Where Do We Begin?"

    Patient Presentation
    A 4-year-old male came to clinic with concerns by the preschool teacher that he would not be ready for kindergarten the following year. The parents were highly educated and very anxious that the teacher said he had difficulty with focusing on tasks that were primarily verbal in nature. He seemed to not understand what was being asked, didn’t ask for clarification, and got frustrated with the tasks easily. The problem appeared to be compounded when it was a multi-step task or when working in a group. The teacher complained that he would finish the task but took an extraordinary amount of time. The teacher also said he had problems sitting still in circle time and preferred unstructured physical activities. The parents and teacher both reported his language skills seemed appropriate for his age in that he could understand and answer with appropriate language to a direct question. His parents describe him as a very active child who would spontaneously run away, climb object or other semi-dangerous activities. Connor scales that the teacher sent showed ratings of inattention and some impulsivity. The past medical history showed that he was bilingual with parents being fluent in both languages themselves. He had passed his newborn hearing test. The family history revealed an uncle with some problems in school but he had finished high school and was a successful small business owner.

    The pertinent physical exam showed a happy, sociable child with growth parameters in the 50-75% and normal vital signs. His physical examination was normal. During the interview, the child’s spontaneous speech was appeared normal in content and production. When the physician asked him to name body parts or identify pictures, he could do it but seemed to have more trouble finding the words. Then he was asked to describe what various items in the office did, he again hesitated and would motion the action. The diagnosis of a probable language problem and possibly some attention issues was made. The parents were very anxious and the father said, “Where do we begin?” after he was told of the possible problems. The physician noted how this was the beginning of a new process to increase their understanding of their child, emphasizing that he had both strengths and weaknesses. In addition to a hearing evaluation, the family decided they wanted to be referred to both a speech pathologist and a psychologist who could evaluate him for attentional issues and other possible learning issues. The family would contact the local school and begin the school-based process for evaluating and determining what educational services he may need to be successful in kindergarten. The pediatrician described briefly the special education process including individual education plans and accomdation plans. To help the family’s anxiety, the pediatrician recommended they begin a file to gather all the information about him in one place. “Basically, anything that has to do with him and his learning should probably be all put in one place until you know what you need,” the pediatrician noted. The mother wanted to know exactly what should be in the file. The pediatrician said he wasn’t sure, but to start with the teacher’s Connor’s scales, the evaluation reports, notes from any meetings, information from the preschool or kindergarten, etc. He also mentioned that the family would probably go and do research on their own and recommended to put all of that in the file too as references.

    Discussion
    Diagnosing and treating learning disabilities is similar to the medical process. A history of problems and concerns is taken, the differential diagnosis considered, appropriate evaluation conducted, hopefully a diagnosis made, development of an educational treatment plan, and follow-up to see how well the treatment plan is working. But like any system that provides care, the educational system has its own vocabulary, processes and rules that need to be understood and gone through.

    Special education is a variety of educational and other services that are designed to provide each child with an equal education. While there are many federal laws that have to be followed, each state basically oversees the school districts and other educational programs within their borders, therefore there are some differences between states. An administrative/legal process must be gone through to determine if a child is eligible for special education services, what services are needed and how they will be delivered. There are different names for this process, but it is often called the IEP process (or individualized educational plan) where parents, teachers and administrators together develop an educational plan for the child. This includes what services are needed, how they will be delivered, by whom, what are the expected results and a follow-up timeline to determine effectiveness of the plan (i.e. is it actually working for the child?). There is a similar administrative/legal process for children who may not qualify for special education or an IEP, but still need some special help to be successful in the classroom. This is sometimes called a 504 plan or accomodation plan. In 504 plans, the idea is that reasonable accomdations are made (usually in the regular education classroom) that does not require more intensive special education help. For example, a child with memory or organizational issues is allowed to tape record the class lecture, or a child with attention deficit disorder can be moved to the front of the classroom to minimize distractions. Children with special medical needs may also need accomdations (i.e. a diabetic allowed to leave classroom to check glucose) and therefore may have a 504 plan. A specific health care plan may also be part of their 504 or IEP plan.

    Learning Point

    Parents who are at the beginning of understanding the educational system for special education are often overwhelmed by the process. Even parents who are well acquainted with the process can need help in organizing the information so they can self-educate, understand the educational plan for their child, and communicate effectively with educational professionals. Organizing all the documents for a child with educational special needs doesn’t have to be difficult or elaborate. The goal is to be able to find the appropriate information easily when it is wanted.

    A binder, file folder or electronic file folder is an easy way to put all the information in one place. Some people will keep the information in more than one place – for example, keep all the e-mail communication on a computer and all the printed information in a file folder. If more than one form is used then it is easiest to use the same basic organization and labels. Some people will also choose to transfer the information from one form to another. For example, some people will scan every paper document into an electronic format and then file all the information in one place. Others will choose to print all electronic information and file it in a binder.

    Keep the organization consistent, especially if using more than one place to store the information. For example, calling a topic “school evaluations” in both places will make searching easier. Many people find organizing by topic and then organizing within a topic chronologically is a good strategy. For example, the child’s report cards are all together in a group with the most recent at the front. Other people will organize the opposite way, chronologically first and then by topic (e.g. all information for year 2010 etc.)

    Keep the labels used easy to understand – Report cards, school evaluations (e.g. special education teacher report), private evaluations (e.g. privately-hired psychologist report), etc. This is especially important if more than one parent/guardian is using the documents.

    If using paper, mark the topics to be able to quickly find them with sticky notes, tabbed dividers, colored paper etc.

    • Initial Basic List of Topics
      • IEP or 504 Plans
      • Other plans – health care plan
      • Report Cards
      • Evaluations – school, private-hired professionals
      • Communication – school, private-hired professionals, legal
      • Meeting notes (including telephone) – school, privately-hired professionals, legal, other
        • Pre-meeting notes – questions to bring up, information to provide
        • Who was present
        • What was discussed
        • What the outcome/action plans is/are
        • Who will carry out the outcome/action plans
        • Timeline for carrying out the outcome/action plan
      • Educational treatment – what was done to help, outcome of the treatment. For example, X reading program was used and parts a, b, and c were found to be helpful but d and e made the child anxious.
      • Legal Notices and Information
    • Advanced List of Topics
      • To Do List – what needs to be done and when it is time to check up on someone else
      • Short Chronology – like a medical record of what has happened over time. This is especially helpful when trying to determine when something occurred. Information about the particular event can then be found more easily.
      • List of Contacts – list of people involved, title/role, contact information
      • Contact Log – list of all contacts chronologically, or telephone log
      • General Background Information – newsletters, magazines, websites etc.
      • Commonly used information – blank or partially filled in consent forms that can be copied and signed
      • Examples of Schoolwork
    • Other Ideas
      • If a binder is used, some people will include a pencil bag with office supplies, or even a recloseable plastic bag to keep receipts for tax purposes in.
      • A writing table or extra paper are always useful for taking notes.

    Questions for Further Discussion
    1. What is the differential diagnosis of language problems or attentional issues?
    2. How do you refer a child for special education services in your local area?
    3. What services are available for children with special education needs in your local area?

    Related Cases

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Speech and Communication Disorders and Attention Deficit Hyperactivity Disorder.

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

    To view images related to this topic check Google Images.

    Navigating the Special Education Process. LDOnline.
    Available from the Internet at http://www.ldonline.org/parents/navigating (rev. 2010, cited 8/23/10).

    Organizing Your Child’s Special Education File: Do It Right!. Wrightslaw.
    Available from the Internet at http://www.fetaweb.com/03/organize.file.htm (rev. 7/21/08, cited 8/23/10).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.
    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.
    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.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

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

  • What Are Significant Contraindications for Breastfeeding?

    Patient Presentation
    A 2-month-old female came to clinic for her health supervision visit. She was doing well in all areas including breastfeeding. The past medical history showed a mother who was Southeast Asian and who was Hepatitis B surface antigen positive. The infant had received Hepatitis B Immunoglobulin and Hepatitis B vaccination within 4 hours of delivery.

    The pertinent physical exam showed a developmentally appropriate infant with growth parameters in the 50-75%. Her examination was normal including no jaundice or hepatomegaly. The diagnosis of a healthy infant with normal growth and at risk for vertical transmission (during pregnancy/delivery) of Hepatitis B was confirmed. During staffing with the attending physician, the resident noted that he was unsure if Hepatitis B was a contraindication to breastfeeding. He had reviewed the American Academy of Pediatrics website and had confirmed that breastfeeding was permitted. Together the staff and resident reviewed the proper protocol from the State Department of Public Health for immunizing the infant for Hepatitis B and when follow-up laboratory evaluation including serology was recommended. The child received her regular set of vaccinations including Hepatitis B and was to return at 4 months of age.

    Discussion
    Hepatitis B is a viral disease transmitted through blood and blood-derived fluids. It has not been noted to be transmitted by breastmilk. Chronic hepatitis B has a high prevalence rate (>8%) in all areas of Africa, Southeast Asia, much of the Middle East, parts of the Amazon River basin and the Caribbean. Chronic Hepatitis B can cause chronic liver disease, cirrhosis, and liver cancer.

    Incubation is about 90 days for acute infection. Only about 30-50% of patients with acute Hepatitis B infection may be clinically symptomatic. Some patients particularly those that are young (<5 years) or immunosuppressed are often asymptomatic. Anorexia and malaise precedes jaundice by 1-2 weeks. Jaundice, abdominal pain, nausea and emesis are frequent symptoms. Other symptoms may include arthritis, joint pain and rashes. The case-fatality rate for acute Hepatitis B infection is about 1%. Acute Hepatitis B infection causes chronic Hepatitis B infection in 30%-90% of persons infected as infants or young children but this decreases to <5% of adolescents and adults.

    Learning Point
    Breastfeeding has numerous advantages for both the infant and mother. Since it is the main way nature intended for infants to be fed, it should not be surprising that there are few definitive contraindications to breastfeeding that are recommended. Most mothers should breastfeed infants through common illness such as viral illnesses, cystitis, mastitis, vaginitis, etc. Women presenting with many of these problems have most likely already exposed the infant, and withholding breastfeeding may actually decrease the maternal antibodies and other protective factors in the milk the infant would receive. Infants born to a Hepatitis B surface-antigen positive mother are recommended to breastfeed.

    Even when there are definitive contraindications for breastfeeding, weighing the risks and benefits for both the mother and infant, may still, on the whole, promote breastfeeding over formula feeding. A good example of this is HIV (Human Immunodeficiency virus). In developing countries where diarrheal illnesses and other infectious diseases can cause high mortality in infants, the benefits to the infant of breastfeeding by an HIV+ mother outweighs the risks of possible transmission of the virus. However, this balance goes in favor of formula feeding in developed countries where diarrheal and other illnesses are a much smaller percentage of morbidity and mortality.

    Maternal and infant exposure to heavy metals (e.g. lead, mercury, arsenic, cadmium, etc.) and environmental contaminants (e.g. PCB, PBB, etc.) in low levels usually are not breastfeeding contraindications. Of course if the mother’s own physical condition does not enable her to breastfeed (e.g. severe illness, trauma, mental instability, etc.) then formula feeding would obviously be recommended. Most drugs are compatible with breastfeeding, but depend on the agent and timing. LactMed is a drug database with breastfeeding safety information

    .
    According to the American Academy of Pediatrics and the Canadian Pediatric Society, the following are considered definitive contraindications to breastfeeding:

    • Infants with Special Dietary Requirements
      • Galatosemia
      • Phenylketonuria – may be partially breastfed
    • Maternal Infectious Disease
      • Cytomegalovirus – may or may not breastfeed depending on individual circumstances
      • Herpes – if active on breast, may use other breast if not affected
      • HIV – may or may not breastfeed depending on individual circumstances
      • Human T-Lymphotropic Virus type 1 or 2 infection
      • Tuberculosis – if not contagious or may resume feeding after two weeks of treatment
    • Maternal Drugs – See LactMed for full drug information
      • Chemotherapy agents – certain agents, discontinue breastfeeding for as long as they remain in the milk
      • Drugs of abuse – discontinue breastfeeding until drugs are out of maternal system
      • Primaquine and Quinine – contraindicated if either infant or mother has G6PD
      • Metronidazole – discontinue breastfeeding until at least 12-24 hours after medication
      • Sulfa drugs – may be a problem in infants with jaundice or G6PD, stressed or premature
      • Radioactive isotope – discontinue breastfeeding for as long as the radioactivity is in the milk

    Questions for Further Discussion
    1. What are common breastfeeding problems for infants?
    2. What are common breastfeeding problems for mothers?
    3. What are the local laws regarding breastfeeding?

    Related Cases

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Breastfeeding and Hepatitis B.

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

    To view images related to this topic check Google Images.

    American Academy of Pediatrics Policy Statement. Breastfeeding and the Use of Human Milk. Pediatrics. 2005;115:496-506. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496#SEC3 (rev. 2/2005, cited 8/18/2010).

    Canadian Pediatric Society. Maternal Infectious Diseases, Antimicrobial Therapy or Immunizations: Very Few Contraindications to Breastfeeding. Can J Infect Dis Med Microbiol. 2006 Sep-Oct; 17(5): 270-272.
    Available from the Internet at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095084/ (rev. 2006, cited 8/18/2010).

    Centers for Disease Control Traveler’s Health Yellow Book. Hepatitis B.
    Available from the Internet at http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.aspx (rev. 7/27/2009, cited 8/18/2010).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.
    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.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • 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.

    Author

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

  • What Causes Peripheral Neuropathy?

    Patient Presentation
    A 20-year-old right-handed male came to clinic with complaints of numbness and tingling in the right lower part of his forearm, 4th and 5th digit and lateral hand. The problem had been increasing over the past month. In particular it increased over the day and was best in the morning. It also got worse day to day over the work week and was better on the weekends. He also complained of some general shoulder and neck muscle pain that he described as cramping, which also improved with rest. He had started a new summer job about 5 weeks previous where he did extensive computer work. He said that the keyboard and mousepad were on top of a solid desk with the monitor in front of the keyboard. He showed the examiner how he had to place the lateral aspect of his right lower forearm across the edge of the desk. He used other computers at home but said that he had a separate tray for his keyboard and mouse that were lower in height than the edge of the desk he worked on, and the edges of the tray were padded. He also played a variety of videogames with hand or lap controllers. He denies any new medications or toxin exposure. The past medical history was non-contributory. The family history revealed no neurological or genetic abnormalities.

    The pertinent physical exam showed a healthy male with normal vital signs and growth parameters. His musculoskeletal examination showed very tight muscles of the neck and shoulder girdle bilaterally. His neurological examination was normal except for pain and numbness in the ulnar nerve distribution of the right lower forearm and hand. Strength was normal. The diagnosis of an acute, focal peripheral neuropathy secondary to ulnar nerve compression along with general muscle spasm of the neck and shoulders was made. He was instructed to suspend all computer work until he had normal sensation. He was given an information prescription of Internet resources on how to properly set-up a computer workstation so that it would be ergonomically appropriate for him. He was also instructed to take frequent short breaks, and to do intermittent stretching of his body. He was to return to clinic if the symptoms persisted or changed. At his next health supervision visit, he reported no problems after he had changed his workstation.

    Discussion
    Peripheral neuropathy is simply a disease of the peripheral nerves. They can be acute (30%) or chronic (about 67%). About 70% of chronic neuropathy in children is hereditary, 20% is indeterminant and 10% is acquired. Peripheral neuropathies are often present with predominantly distal involvement that is bilateral and symmetric. Sensory symptoms can include numbness, dysesthesia or ataxia. Motor symptoms often include weakness. The autonomic nervous system can also be affected with arrhythmias, hypotension, bowel or bladder problems or abnormal sweating.

    Learning Point
    The differential diagnosis of peripheral neuropathy includes:

    • Neurologic
      • Abetaliporteinemia
      • Charcot-Marie Tooth Disease
      • Chronic Inflammatory Demyelinating Polyneuropathy
      • Dejerine-Sottas
      • Giant Axonal Neuropathy
      • Guillian-Barre Syndrome
      • Hereditary Sensory Neuropathies – Familial Dysautonomia
      • Ischemic Monomelic Neuropathy
      • Mononeuritis Multiplex
      • Metachromatic Leukodystrophy
      • Refsum Disease
    • Infectious Disease
      • Chagas Disease
      • Diphtheria
      • Leprosy
      • Lyme Disease
      • Rabies
      • Tick Paralysis
    • Rheumatic/Inflammatory
      • Churg-Strauss Syndrome
      • Henoch-Schonlein Purpura
      • Inflammatory Bowel Disease
      • Juvenile Rheumatoid Arthritis
      • Polyarteritis Nodosa
      • Sarcoidosis
      • Sjogren’s Syndrome
      • Systemic Lupus Erythematosus
      • Wegener’s Granulomatosis
    • Specific Diseases
      • Celiac Disease
      • Chronic Illness Polyneuropathy
      • Cystic Fibrosis
      • Diabetes Mellitis
      • Hypothyroidism
      • Porphyria
      • Malignancy
      • Renal Failure/Uremia
      • Transplantation – Bone Marrow, Liver
      • Vitamin Deficiency – B1, B2, B6, B12, E
    • Drugs
      • Alcohol
      • Anti-retroviral medications
      • Antibiotics – chloramphenicol, isoniazid, metronidazole, nitrofurantoin, penicillin, sulfonamide,
      • Chemotherapy
      • Phenytoin
      • Thalidomide
    • Toxins
      • Arsenic
      • Lead
      • Mercury
      • n-Hexane
      • Organophosphates
      • Thallium
    • Other
      • Epidemic neuropathy
      • Factitious
      • Idiopathic – Bell’s palsy
      • Mechanical – brachial plexus injury, injections, pressure,

    Questions for Further Discussion
    1. What types of evaluation can be considered for peripheral neuropathy?
    2. What are indications for evaluation by a neurologist?
    3. What are common health problems associated with using computers?

    Related Cases

      Symptom/Presentation: Pain

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Peripheral Nerve Disorders

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

    To view images related to this topic check Google Images.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2280-2285.

    Cruse, RP. Overview of Acquired Peripheral Neuropathy in Children. Up To Date.
    Available from the Internet at http://www.uptodate.com (rev. 1/13/2010, cited 8/13/2010).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively 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.
    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.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

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