Weight Loss: The Journey of a Thousand Miles Begins with One Step

Patient Presentation
A 6-year-old male came to clinic for a health supervision visit. The entire family was overweight or obese. The family had instituted some healthier eating habits after a 40+ year old uncle had a heart attack. The boy said that he was choosing the 1% white milk at school, but on Fridays he would have his treat of chocolate milk. The mother said that they were eating out only 1 time per week and were trying to choose better options such as having a hamburger instead of a cheeseburger. The boy said that he liked to cook “his” vegetable too. His mother explained that he would choose one vegetable for the family that he would help prepare during the week. The family had switched to 1% milk from whole milk. The family was trying to be more active too by going for a walk to the local park once per week. “I’d like to do it more, but with work, school and other things, we don’t get to it,” the mother stated. The mother remarked that she had lost about 3 pounds in the past 3 months too.

The pertinent physical exam showed a happy male with a slightly elevated blood pressure at 115/68. His body mass index was 20.1. His weight was 250 g down from his weight 3 months ago. His height was 1 cm increased from 3 months ago, and 1.75 cm over the past 6 months. The rest of his examination was negative. The laboratory evaluation from an examination 6 months ago had a normal non-fasting HDL and total cholesterol, glucose, BUN and creatinine were normal. The diagnosis of obesity was made. The physician applauded the family for making some very good changes to their diet. The physician encouraged them to make additional changes over the next few weeks including trying to exercise at least 3 times per week and to change the milk to skim milk. “That will save about 20 calories a glass,” she noted. When the boy said that pizza was often a choice at school, the physician encouraged him to choose cheese or cheese and vegetable pizza over meat pizza. “Most of the meat on the pizza has a lot of fat,” she said. The physician encouraged the mother to decrease the salt intake by using fewer prepared foods or switching to a lower salt version. The family was to followup in another 3 months.

Discussion
Obesity is unfortunately a growing problem in the United States that is multifactorial. It’s even harder to understand when food insecurity is also a growing problem in the United States. In both obesity and food insecurity, poor nutrition is a common denominator.

Learning Point
Any time someone is trying to change a behavior such as poor nutrition in their life, it can be very difficult. The ultimate goal often seems unreachable but helping people to set reachable intermediate goals and supporting their effort to attain those goals is key to long-term success. While there can be many choices as to which steps to start with on the journey of a thousand miles to better nutrition, there are 3 main elements – amount of food, type of food and the amount of exercise.

  • Amount of food or portion size
    • A child and their family need to understand portion size. In general a portion is the size of the fist, or palm of the hand. A slice of bread or one apple is one portion for an adult, but may be 2-3 for a child.
    • Children and families need to understand what a reasonable amount of food is and stop when that is eaten or before. It is fine to have a slice or two of pizza for a meal, but it is not okay to eat a whole pizza.
    • This is also true of beverages. Soda pop at a national fast food restaurant serves the following sizes:
      • Kids 12 ounces, 110 calories
      • Small 16 ounces, 150 calories
      • Medium 21 ounces, 210 calories
      • Large 32 ounces, 310 calories
      • Diet soda is 0 calories.
      • Apple juice is 100 calories/8 ounces and is another alternative

  • Food type or choosing a healthier option
    • A variety of foods is important for a healthy diet including fats.
      Fats because they are calorically dense (9 calories/gram, versus protein and carbohydrates 5 calories/gram, and ethanol 7 calories/gram) are sometimes vilified, but they are critical for good nutrition.
      Fat however is often hidden in foods and the same/similar taste and texture can often be achieved by choosing alternatives.

    • For example, whole milk has about 3.25% fat and has 146 calories/8 ounces, while 2% milk has 122 calories and skim milk has 83 calories.
      Changing from whole milk to 2% saves 24 calories, and changing to skim milk saves 63 calories. After only ~9 gallons of 2% milk or 3.5 gallons of skim milk, the equivalent of 1 pound of weight can be lost (~3600 calories).

    • Similarly, when eating at a fast food restaurant, choosing a hamburger instead of a cheeseburger eliminates ~95 calories (1 slice American cheese). Choosing cheese pizza instead of a meat pizza eliminates ~50 calories/slice. Chocolate milk has 170 calories instead of 146 calories for white milk.

  • Shopping for food
    • Shop at the perimeter of an US food store where the cold refrigeration is. This is where fresh fruits and vegetables, meats and dairy cases are. Processed foods have longer shelf lives and therefore are often located in the middle of the store.
    • Purchasing food that only one’s grandparents would recognize. While there are many improvements in food quality and convenience through improved packaging, processed foods also often have unnecessary fats, salt and other ingredients that do not necessarily add to their nutritional quality. Processing may also decrease their nutritional quality. They also are frequently more expensive.
    • Having the children choose one or more foods to prepare at home also helps them to be invested in their own nutrition.

  • Exercising more
    • There are many ways to increase exercise in one’s daily life including walking (park at the far end of a lot and walk in), climbing stairs (walk up 1-2 flights instead of taking the elevator) and even just playing on a playground for 30 minutes (~200 calories).
    • For more information about exercise see How Far is 10,000 Steps?

  • Miscellaneous
    • “Saving up calories” for a special treat or extra portion once in a while is perfectly fine, but planning for it when possible helps.
      If the family knows that there is going to be a birthday party, then they can plan to not have a dessert or not have a third portion of another food to “save the calories” for the birthday cake.

    • Have another alternative generally available such as a diet soda, popcorn, graham crackers, etc. for the unexpected social occasion where food and drink would be expected.

Questions for Further Discussion
1. What other nutrition counseling tips do you have?
2. What obesity screening laboratories are recommended?
3. What local resources are available for food insecurity?
4. What local resources are available for exercise opportunities?

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: Obesity in Children, Exercise for Children, and Child Nutrition.

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

To view images related to this topic check Google Images.

Pollan M. Food Rules. Penguin Press. New York, NY. 2009.

McDonald’s. McDonald’s USA Nutrition Facts for Popular Menu Items. Available from the Internet at http://nutrition.mcdonalds.com/nutritionexchange/nutritionfacts.pdf (rev. 9/9/11 cited 5/21/2012).

US Department of Agriculture. ChooseMyPlate.gov. Available from the Internet at http://www.choosemyplate.gov/ (cited 5/21/2012).

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.
    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
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author

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

  • What Are Indications for Allergy Testing?

    Patient Presentation
    A 2-year-old female came to clinic with a rash that was not improving. She had a history of atopic dermatitis since infancy that was treated with lotion once a day. About 1 month previously, she had been given picrolimus at another facility but her mother did not apply it as a friend told her it was very strong medicine. The friend also told the mother that perhaps the child had food allergies as the cause of the rash, so the mother requested testing. The girl had no history of asthma, difficulty breathing, diarrhea or abnormal stools, bloating, rhinorrhea, and was following her 50-90% growth curves. The mother denied pruritis or irritability, or changes in the rash with different foods. The past medical history of two episodes of otitis media treated with amoxicillin was made. The family history was positive for asthma in the mother’s family and seasonal allergic rhinitis on both sides of the family. There was no known food, drug or animal allergies.

    The pertinent physical exam showed a well-appearing female with normal vital signs. HEENT demonstrated no atopic pleats and the mucosa appeared normal. Lungs were clear. Skin examination showed diffuse dry skin especially on the arms, legs and trunk. She had several areas of redness on her left leg and ventral trunk. Behind the left knee there was a 4 cm round area with mild lichenification and erythema. There was no scale seen. She did pull at her arms and legs during the examination.

    The diagnosis of atopic dermatitis was made. The mother was educated extensively verbally and with written documents about the natural history of atopic dermatitis and the importance of emollients as a mainstay of therapy. The mother was also educated about improved bathing practices and how and when other medications such as topical steroids should be used. Overall the plan was to begin an oral antihistamine to decrease pruritis, increase the frequency and amount of thick ointments, use of a low potency (Level VI) topical steroid to the swollen, reddened areas for 4-5 days, and bathing with an unscented body bar for soap. The physician didn’t recommend using the picrolimus at this time as a steroid had not been tried yet. The physician explained that although food allergies could be contributing to the atopic dermatitis, that it appeared that she had been undertreated. She also did not have other symptoms that pointed toward a food allergy. The mother agreed to implement the treatment plan and 1 month later the child’s skin had much improved with fewer dry spots and no areas of swelling. The lichenified area appeared to be improving slightly. The mother said that her daughter wasn’t itching as much either, now that she knew that grabbing clothing signaled itching. The mother still had concerns about food allergies but agreed to continue treating and monitoring the patient.

    Discussion
    When to send a patient to an allergist/immunologist sometimes is very clear such as a patient with angioedema and respiratory problems after an insect sting or contact with latex, but many common problems may need appropriate followup and monitoring before a referral is considered.

    Allergists are trained to perform and interpret diagnostic information that may not be available to generalists such as specific in vitro testing, skin testing and can perform provocative challenges such as methacholine challenges for asthma. Additionally, an allergist/immunologist makes daily and emergency management plans and gives education to carry out those plans for challenging patients such as those with potential anaphylaxis or immune deficiency. Other treatment modalities available include drug desensitization and immunotherapy.

    Allergists/immunologists are usually necessary for diagnosis and treatment of:

    • Anaphylaxis
    • Angioedema and urticaria
    • Allergic disease caused by drugs, food, and latex
    • Allergic disease associated with
      • Allergic bronchopulmonary aspergillosis,
      • Aspirin exacerbated respiratory disease
      • Occupations – allergic sensitization to food, animals, etc.
    • Hypersensitivity pneumonitis
    • Insect hypersensitivity
    • Primary immune deficiency

    Allergists/immunologist may also be helpful for:

    • Asthma
      • Confirming the diagnosis
        • Challenge testing including exercise or methacholine
        • Correlation of history with specific IgE testing
      • Identifying etiology/role of agent
        • Environmental cause (ie dust mite, pollen, etc.)
        • Food
        • Drug
        • Occupational or other exposure
      • Improving management/outcome of patients with
        • Potentially fatal asthma
        • Moderate to severe persistent asthma
        • Poor control despite apparent appropriate therapy
        • Using excessive amounts of medication
        • Poor control because of possible non-adherence, education, support, including improving environmental management
        • Multiple hospitalizations and/or emergency department visits
        • Associated rhinitis or sinusitis
      • Improving by
        • Education
        • Environmental control
        • Optimal medication choice and use
    • Conjunctivitis or Rhinitis
      • Confirming the diagnosis
        • Seasonal allergic rhinitis/conjunctivits
        • Other cause
      • Identifying etiology/role of agent
        • Correlation of history with specific IgE testing
        • Specific allergen testiing
      • Improving management/outcome through
        • Education
        • Environmental control
        • Optimal medication choice and use, including immunotherapy in certain patients
    • Dermatitis
      • Confirming the diagnosis
        • Atopic dermatitis
        • Contact dermatitis – patch testing
        • Other cause
      • Identifying etiology/role of agent
        • Environmental cause (ie dust mite, etc.)
        • Food
      • Improving management/outcome of patients with
        • Poor control despite apparent appropriate therapy
        • Using excessive amounts of medication
        • Poor control because of possible non-adherence, education, support
      • Improving by
        • Education
        • Optimal medication choice and use
    • Sinusitis
      • Confirming the diagnosis
        • Allergic fungal sinusitis
        • Seasonal allergic rhinitis
        • Immunodeficiency
      • Improve management/outcome through
        • Education
        • Environmental control
        • Optimal medication choice and use, including immunotherapy in certain patients including treatment of
          • Associated immunodeficiency
          • Fungal disease
          • Associated eosinophilic inflammation
          • Nasal polyps

    Learning Point
    Indications for allergy testing include:

    • Asthma – patients exposed to indoor allergens with persistent asthma
    • Allergy, suspected – to food, drug, insect sting, latex or other similar identifiable allergens
    • Rhinitis – patient’s symptoms not controlled by avoidance and medication

    Questions for Further Discussion
    1. What standard extracts for allergic skin testing are available?
    2. How does immunotherapy for allergies work?
    3. What is the definition of food allergy?

    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: Allergy, Food Allergy and Eczema.

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

    To view images related to this topic check Google Images.

    Li JT. Allergy Testing Am Fam Physician. 2002 Aug 15;66(4):621-625. Available from the Internet at http://www.aafp.org/afp/2002/0815/p621.html (rev. 8/15/2002, cited 5/15/2012).

    American Academy of Allergy Asthma and Immunology. How the Allergist / Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence. J Allergy Clin Immunol 2006 Feb;117(2 Suppl Consultation):S495-523. Available from the Internet at http://www.guidelines.gov/content.aspx?id=9334&search=allergy+testing+in+children (rev. 2/2006, cited 5/24/12).

    American Academy of Allergy Asthma and Immunology. How the Allergist / Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence. Primary Care Summary. Available from the Internet at http://www.aaaai.org/practice-resources/Consultation-and-Referral-Guidelines/Primary-Care-Summary.aspx (rev. 2012, cited 5/15/12).

    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.
    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.

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

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    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.

    Author

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

  • What Are the Side Effects of Immunosuppressive Medication?

    Patient Presentation
    A 13-year-old male came to the general pediatric clinic with malaise. He had a liver transplantation at age 5 because of a viral insult, and had acute rejection 4 months after the transplantation. About 10 days ago, he had gotten an upper respiratory infection with cough and fever. After 3 days his fever resolved and his acute symptoms seemed to improve, but he continued to be tired. The malaise was increasing with him sleeping after returning from school and going to bed early. He was eating but especially less over the past 36 hours. The review of systems revealed no pain, fever, cough, changes in stool color or consistency, and no changes in urine color but he had less frequency, He denied jaundice, but his mother noted very mild icterus. The past medical history found that he had done well with only 2 other hospitalizations for skin infections that necessitated intravenous antibiotics because of his immunosuppression. He did not have chronic rejection and his medication levels (Cyclosporin A and tacrolimus) were stable.

    The pertinent physical exam found him to be afebrile with normal blood pressure and other vital signs. His weight was 50% and height was 10%. HEENT examination found mild scleral icterus, but none in the oral mucosa. Lungs were clear and there was no heart murmur. Abdomen examination had a chevron scar with liver edge down 2 cm from right costal margin and non-tender. There were no masses. Skin had no jaundice including on the creases of palms and soles. He was Tanner stage 3. The laboratory evaluation found very elevated transaminases, bilirubin and alkaline phosphatase. Later testing found immunosuppressive medication levels consistent with his outpatient levels that were normal. Viral panels were negative. The diagnosis of probable acute rejection was made and the patient was admitted to the transplantation service. Liver biopsy confirmed the diagnosis. After the laboratory testing became available, it was assumed that the acute rejection was due to viral suppression and not due to non-adherence. He was given corticosteroids and the patient’s clinical course over the next 5 days improved and he was sent home on a steroid course and close followup.

    Discussion
    Although this patient did not have rejection because of non-adherence to his treatment regimen, he is entering a time of his life where he is vulnerable to late graft loss because of non-adherence. Overall, late graft loss is less likely for pediatric/adolescent patients because many of the reasons for the transplantation do not recur in the graft.

    Non-adherence is one of the most important predictors of rejection and contributes to late graft loss for liver transplant patients. Non-adherence with treatment regimens is unfortunately common. There are 3 general types of non-compliance:

    • Accidental – Patients inadvertently forget to take their medication. This is often the easiest to fix because patients wish to comply. Generally seen in older patients but adolescents with different schedules and often fewer organization skills may have this problem.
    • Invulnerable or immortal – Patients have beliefs that not complying will not have adverse effects. Often seen in younger patients and those with less education. Adolescents often believe they are invulnerable and rejection and other problems won’t happen to them.
    • Decisive – Patients independently and actively decide not to comply which is the most difficult to fix. Patients are younger and less educated and often have misunderstandings about how the medications work. Adolescent patients also have this problem as they normally are trying to develop more autonomy and control in their lives. This is also a peak time for risk taking.

    Besides adolescence, another very vulnerable time for non-adherence and graft rejection is when patients are being transferred to adult services.
    Previous poor self-management unfortunately often predicts poor transition and non-adherence.

    Self-care and management are extremely complex even for adults with adequate education, resources and support.
    Adolescents and young adults can be even more challenged because of their normal development, changes in living environment (i.e. living at home and/or college), potentially fewer resources (ie less convenient transportation, changes in health insurance, money to pay for medication co-pays and other expenses, etc.) and potentially fewer social supports (ie more perceived or real dependence upon friends than family). Below are some examples of self-care and management that adolescents and young adults would be required to do to be compliant with their treatment.

    • Take all medications when and how prescribed (sometimes 4-5 times/day, with multiple pills and/or weekly or monthly medications also)
    • Make appointments and go to appointments
    • When ill, understand how health system works and how to obtain care
    • Obtain blood work and follow up on results
    • Obtain and understand health insurance and pay bills
    • Comply with diet and exercise regimens, limit or abstain from alcohol, perform safe sex practices
    • Obtain and comply with dental or mental health care and other health care regimens

    Learning Point
    Immunosuppressive medications have multiple primary effects that necessitate management and direct side effects. Many drugs cause problems that then need additional management such as nephrotoxicity caused by Cyclosporin A. Many drugs also cause cosmetic problems which are distressing to patients especially adolescents who place great important on immediate effects (ie. decrease the acne and hirsuitism) and less on the longer term effects (ie. decreasing the risk of chronic rejection).

    All the medications below cause immunosuppressive problems including infection and malignancies especially post-transplant lymphoproliferative disease.

    Main side effects of these immunosuppressive medications are listed below (***are particularly common):

    • Azothioprine
      • *** Bone marrow suppression
      • GI upset
      • Hepatotoxicity
      • Cosmetic – alopecia
    • Corticosteroid
      • Amenorrhea
      • Bone abnormalities – osteopenia, avascular necrosis
      • Dyslipidemia
      • Electrolyte abnormalities – hypernatremia
      • Glaucoma and cataracts

      • GI upset
      • Growth deficiency
      • Hypertension
      • ***Diabetes, post-transplant
      • ***Neurologic effects – myopathy, psychosis and emotional instability
      • Cosmetic – ***acne, hirsuitism, bruising and petechiae, Cushingoid appearance,
        fluid retention, thin skin, poor wound healing, hyperhidrosis
    • Cyclosporin
      • Dyslipidemia
      • Diabetes, post-transplant
      • Electrolyte abnormalities – hyperkalemia, hypomagnesemia, hyperuricemia
      • GI upset
      • Hypertension
      • Neurological effects – headache, paraesthesias, tremor
      • ***Renal failure
      • Cosmetic – acne, ***gingival hyperplasia, ***hirsuitism
    • Tacrolimus
      • Dyslipidemia
      • Diabetes, post-transplant
      • ***Electrolyte abnormalities – hyperkalemia, hypomagnesemia
      • GI Upset
      • Hypertension
      • ***Renal failure
      • ***Neurological effects
      • Cosmetic – alopecia
    • Sirolimus
      • Bone abnormalities – arthralgia, bone pain
      • Bone marrow suppression
      • ***Dyslipidemia
      • GI upset
      • Pulmonary infiltrates
      • Cosmetic – acne, poor wound healing, rash, mouth ulcers
    • Mycophenolate mofetil
      • Bone marrow suppression
      • ***GI upset
    • Alemtuzumab
      • Bone marrow suppression
      • ***GI upset
      • ***Infusion reactions
      • Cosmetic – rash
    • ATG or thymoglobulin
      • ***Bone marrow suppression
      • GI upset
      • ***Infusion reactions
    • OKT3 or muromonab CD3
      • ***Bone marrow suppression
      • GI upset
      • ***Infusion reactions

    Questions for Further Discussion
    1. What are the most common solid organs transplanted into pediatric patients?
    2. What is the life span of a solid organ transplant in pediatric patients?
    3. Can transplant patients ever stop immunosuppressive medications?
    4. Should live virus vaccinations be given to patients with solid organ transplants?

    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 this topic: Organ Transplantation and Liver Transplantation

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

    To view images related to this topic check Google Images.

    Morrissey PE, Flynn ML, Lin S. Medication noncompliance and its implications in transplant recipients. Drugs. 2007;67(10):1463-81.

    Bucuvalas JC, Alonso E. Long-term outcomes after liver transplantation in children. Curr Opin Organ Transplant. 2008 Jun;13(3):247-51.

    Shemesh E, Annunziato RA, Arnon R, Miloh T, Kerkar N. Adherence to medical recommendations and transition to adult services in pediatric transplant recipients. Curr Opin Organ Transplant. 2010 Jun;15(3):288-92.

    Schonder KS, Mazariegos GV, Weber RJ. Adverse effects of immunosuppression in pediatric solid organ transplantation. Paediatr Drugs. 2010;12(1):35-49.

    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.
    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.
    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.

    Author

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

  • What Causes Vulvar Masses?

    Patient Presentation
    A 21-year-old female came to clinic because of a mass on her left labia majora. She said she had noticed it two days ago after a long bike ride. It was slightly painful since then, especially with walking. She had tried soaking in a bathtub with some relief. She denied any overt trauma, vaginal discharge, dysmenorrhea, abdominal or pelvic pain or fever. Her last sexual encounter was 6 months previously and she had used condoms and foam for sexually transmitted infections and pregnancy prevention. The past medical history showed an ankle sprain and head injury because of athletics. The pertinent physical exam showed a healthy female with normal vital signs. Genitourinary examination found a 3 mm red/yellow knobbly lesion at 3 o’clock on the labia majora. It did not extend to the labia minora. There was no punctum seen. The surrounding skin was mildly erythematous and was very mildly painful with palpation. There was no streaking of the erythema. Individual hair follicles appeared normal in the area. No vaginal discharge was seen and the rest of the tissue appeared healthy.

    The diagnosis of epidermal inclusion cyst was made. The patient was counseled that this was a common problem and usually resolved. The lesion probably had been there but was not noticed until the surrounding skin became irritated after the long bike ride. The patient was instructed to wear loose clothing until the erythema resolved, along with sitz baths. The physician also commended using an anti-chaffing product for biking and similar activities with strict perineal hygiene after exercise. The patient was to followup if the pain did not resolve or increased, the lesion became larger or other symptoms developed.

    Discussion
    Vulvar disease in children and adolescents often involves the skin structures with contact dermatitis, vaginal/perianal streptococcus infection, folliculitis, herpes labialis and similar problems causing much of the complaints. Trauma from straddle injuries and sexual abuse also are part of the differential diagnosis. Vulvar masses do occur but are somewhat less common in the pediatric population. Usually the vulvar mass diagnosis is made clinically by history, location and appearance, and most vulvar masses are benign. Treatment for vulvar masses may be necessary because of location and pain/irritation secondary to size and movement.

    Learning Point
    Common vulvar masses includes:

  • Bartholin gland cyst
    • Location: 4 and 8 o’clock of the labia majora, classically crosses the labia minora
    • Appearance: cystic, usually painless but may be painful
    • Other: may become infected and rarely is malignant
  • Epidermal inclusion cysts
    • Location: labia majora
    • Appearance: small, can be grouped, may be yellowish
    • Firm, nodular with palpation, often asymptomatic
  • Mucous cysts of vestibule
    • Location: vestibule
    • Appearance: superficial, smooth, < 2 cm usually
  • Vulvar fibroma
    • Location: labia majora, perineal body, introitus
    • Appearance: firm, asymptomatic, not cystic
  • Vulvar lipoma
    • Location: labia majora, may be associated with other lipomas on abdomen or thighs
    • Appearance: subcutaneous, soft, fatty lesion, not cystic, usually asymptomatic, may be slow growing
  • Canal of Nuck cyst
    • Location: inguinal crease or anterior labia majora. Does not cross the labia minora
    • Appearance: cystic swelling. Can occur anywhere along inguinal canal or in labia majora
    • Other: remnant of peritoneum
  • Vulvar hematoma
    • Location: anywhere within the vulva
    • Appearance: tense swelling of tissue that appears red and/or bruised, very painful
    • Other: usually has history of trauma
  • Sebaceous gland cysts
    • Location: may occur anywhere as may be ectopic
    • Appearance: firm, small lesions with punctum
  • Inguinal hernia
    • Location: Internal inguinal ring to vulva
    • Appearance: cystic mass which may be reducible
  • Other Vulvar Masses
    • Adenocarcinoma
    • Angiokeratoma
    • Dysontogenetic cyst
    • Endometriosis
    • Gartner duct cyst
    • Hemangioma
    • Hidradenoma – accessory breast tissue
    • Leimyoma
    • Myoblastoma
    • Pyogenic granuloma
    • Skene duct cyst
    • Syringoma
    • Rhabdomyosarcoma
    • Vaginal inclusion cyst

    Questions for Further Discussion
    1. What are indications to consider sexual abuse in a patient presenting with vulvar disease?
    2. What are indications for referral to a gynecologist for vulvar disease?

    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 this topic: Vulvar Disorders

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

    To view images related to this topic check Google Images.

    Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses. Am Fam Physician. 1998 Apr 1;57(7):1611-6, 1619-20.

    Pundir J, Auld BJ. A review of the management of diseases of the Bartholin’s gland. J Obstet Gynaecol. 2008 Feb;28(2):161-5.

    McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008 Apr;88(2):265-83, vi.

    Micali G, et. al. Benign Vulvar Lesions. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/264648-overview (rev. 9/29/11, cited 5/7/12).

    Stockdale CK, Boardman RA. Bartholin Cyst. ePocrates.
    Available from the Internet at https://online.epocrates.com/u/29351060/Bartholin+cyst/Diagnosis/Differential (rev. 6/24/11, cited 5/7/12).

    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.
    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