Patient Presentation
A 9-year-old male came to clinic for his health maintenance examination. He was overall healthy and there were no parental concerns. The past medical history found him to be fully immunized including seasonal vaccines.

The pertinent physical exam revealed him to have normal vital signs and growth parameters that were 10-50%. His examination was normal.

The diagnosis of a healthy male was made. His mother consented to all vaccines but asked why the HPV vaccine was being done at this age as her older daughter had it at 11-12 years. “In our community the vaccine rate was relatively poor. Not in our clinic but in the community. So we as a practice are following the recommendation to start vaccinating at age 9 years. We had a good rate before but now our rates are even higher so we are happy with the results. For some families who might be hesitant it also gives them a little bit more time to learn about the cancers it prevents and become more comfortable with getting the vaccine. Families like it that we can give it with other vaccines too like flu shots,” he responded.

Discussion
Human papilloma virus (HPV) is a circular, double-stranded DNA-virus that is the most common sexually-transmitted infection in the US and in many places world-wide. Diseases range from genital warts to respiratory papillomatosis to cancer. Cancer locations include skin, oropharyngeal, vulvar, vaginal, cervical, anal and penile cancers. It is estimated that HPV infection is associated with ~125,000 cases of cancer annually in the US.

HPV vaccine was initially approved in 2006 in the US with a quadrivalent vaccine. In 2016 a nonavalent vaccine was approved and is the only HPV vaccine currently approved in the US. The vaccine is recommended for ages to be given at 9-14 years with catchup vaccination routinely done up to 26 years, and potentially as late as 45 years of age with shared decision making between patients and health care providers.

Serotypes included are 6 and 11 (rarely carcinogenic but associated with 90% of anogenital warts and recurrent respiratory papillomatosis), 16 and 18 (associated with 70% of cervical cancers, 16 is associated with 95% of HPV-related oropharyngeal cancers), and 31, 33, 45 and 52 (associated with an additional 20% of cervical cancers). HPV prophylactic vaccines work by blocking entry of the virus into cells, presumably by antibody neutralization.

Learning Point
HPV vaccines are highly efficacious with mild side effects. It is estimated that up to 90% of HPV-related cancers are prevented especially cervical cancer. “Studies have […] demonstrated that earlier administration of the vaccines results in greater immunogenicity and long-lasting protection.” Greater effectiveness “”[…] is likely due to administration of these prophylactic vaccines prior to natural exposure to HPV from sexual activity rather than a biological mechanism independent of natural exposure.” It is estimated that up to 60% of adolescents have their sexual debut by age 18 years. It is also estimated that that “most sexually active women and men will become infected with HPV at least once in their lifetime.” Administration at early ages can lead to greater completion of the vaccine series as well.

Older adolescents and adults do have robust antibody responses that are higher than natural infection which likely gives substantial protection against HPV.

Some studies have also reported herd immunity protection effects as well. As the HPV vaccine has been efficacious, especially against cervical cancer, oropharyngeal cancers still are increasing and are now the main type of HPV-related immunity.

HPV vaccines for treatment (as opposed to prophylaxis) are also being developed designed to induce cellular immunity against established infections and potentially prevent continuation to cancer.

Questions for Further Discussion
1. What are treatments for respiratory papillomatosis? A review can be found here
2. What are treatments for genital warts? A review can be found here
3. What are some methods for counseling families who may be vaccine hesitant? A review can be found here

Related Cases

Disease: HPV | Sexually Transmitted Diseases | Childhood Immunization

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: General Pediatrics | Infectious Diseases

Age: School Ager

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 these topics: HPV and Vaccines.

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

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Ellingson MK, Sheikha H, Nyhan K, Oliveira CR, Niccolai LM. Human papillomavirus vaccine effectiveness by age at vaccination: A systematic review. Hum Vaccin Immunother. 19(2):2239085. doi:10.1080/21645515.2023.2239085

Skolnik JM, Morrow MP. Vaccines for HPV-associated diseases. Molecular Aspects of Medicine. 2023;94:101224. doi:10.1016/j.mam.2023.101224

Escoffery C, Petagna C, Agnone C, et al. A systematic review of interventions to promote HPV vaccination globally. BMC Public Health. 2023;23(1):1262. doi:10.1186/s12889-023-15876-5

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

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Patient Presentation
A 13-year-old male came to clinic with a history of bruising. He had been seen in an urgent care 1 month previously where they documented three 2-4 mm bruises and one that was about 8-10 mm on the left side of the abdomen that were just below the umbilicus. The family had noticed them and thought it was unusual so they sought medical care. The history at the time was negative and the laboratory evaluation including a complete blood count, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen, von Willebrand Factor antigen, and Factor VIII were eventually normal. The family was instructed to see their general pediatrician if the bruises returned. The patient had new bruising of 1 day duration, that occurred on the abdomen again and upper outer right thigh. The patient denied any other bleeding including no bleeding with brushing teeth, epistaxis, or hematochezia. He ate a general diet and the family denied any medication history (except ibuprofen 3 days ago for a headache that resolved) or supplements, herbal products or teas. The family denied obvious trauma. The patient during a private interview also denied any trauma and stated that he felt safe at home and school. The answers given were detailed and interactions with the family and patient seemed appropriate to the examiner.

The past medical history was positive for intermittent bruising normal for daily life including shin or lower arm bruising. He had no problems clotting after a cut and cuts/bruises seemed to heal as usual. The family history was also negative for bleeding problems except for the mother who needed a blood transfusion after birth of a sibling. She had no bruising or other bleeding problems herself. The review of systems was negative.

The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters. His general examination was normal including all mucous membranes. His skin showed one 5 mm bruise in the right lower abdomen and a 6 cm roundish bruise on the high right upper thigh near the hip. Both were brown/black and appeared to be about the same stage of healing. There was no obvious petechiae.

The diagnosis of abnormal bruising was made. Additional history revealed that the boy did carry a backpack that he did use the belt clip for. He also wore different belts with different belt buckles. The examiner did not feel that this was inflicted trauma and thought that although this could be unrecognized trauma from the backpack or belt buckles, that this possibly could be an unrecognized platelet or bleeding factor problem. The hematologist by telephone consultation agreed and asked that some labs be repeated (i.e. complete blood count with platelets, PT, PTT, fibrinogen, complete metabolic profile, uric acid, lactate dehydrogenase) but wanted to wait on other labs until they saw the patient. The repeated labs were normal and the patient was awaiting the consultation at 2 week followup.

Discussion
Bruising is a common question asked by families. The toddler and young child who is playing and commonly falling will have bruises on the shins which may worry the family. Other places where a person will have bruises or even abrasions or cuts will be prominences such as the hands, elbows, knees, nose, forehead and occiput of the skull. Bruising in places where it would be expected to try to mitigate a fall are also common such as the outside of the arm or shoulder. Bruising on the spine prominences may also be because of a fall or trying to mitigate one. Injuries may be not recognized such as a bruise on the upper thigh, hip or lower abdomen from hitting the corner of a counter/table with bruise’s placement depending on the height of the individual. A stick could poke someone in the abdomen who didn’t recognize it as they were doing yardwork. Bruises could be the first sign of an underlying problem too such as idiopathic thrombocytopenic purpura or cancer.

Non-accidental trauma is always a potential concern and the age of the child along with the area of the bruising can give clues. Non-mobile children are less susceptible to trauma overall. For any person injuries that appear patterned, clustered or in areas where they are likely to be grabbed or hit such as top of head, face, ears, arms and upper legs are more concerning. Additional injuries such as oral or genital injuries or any head trauma also are more concerning for non-accidental trauma.

The history and physical examination of a patient with a history of abdominal or easy bruising is very important and helps to direct the evaluation. Questions about the personal and family history of bruising or bleeding, along with medications and supplements that are consumed and overall dietary history can be very helpful. Of course many questions need to be asked about potential accidental or non-accidental trauma. Less common problems and those that are qualitative problems may be more difficult to identify and often need specialty consultation.

Potential causes of bruising include:

• Trauma
  • Accidental
    • Witnessed
    • Non-witnessed/unrecognized
  • Non-accidental/inflicted/abuse
    • Clustered or patterned bruising
    • Bruising on areas not commonly occurring – back, head, thighs
• Platelet
  • Thrombocytopenia
  • Function problem
• Clotting factors
  • Deficiency
  • Function problem
• Vitamin K deficiency
• Medications **
  • Anti-platelet including aspirin
  • Non-steroidal anti-inflammatory agents
  • Anti-coagulants including heparin and coumadin
• Supplements **
  • Vitamin E
  • Garlic
  • Gingko biloba
• Cancer and infiltrative disease
• Connective tissue integrity/fragility
  • Arteriovenous malformations
  • Ehlers-Danlos syndrome
  • Glutaric aciduria
  • Osteogenesis imperfecta
  • Vitamin C deficiency (scurvy)

** A list of common medications and supplements that can cause bleeding or bruising can be found here.

Learning Point
Initial laboratory evaluation can include:

• Complete blood count with platelet count
• Prothrombin time
• Activated Partial thromboplastin time
• von Willebrand Factor antigen
• von Willebrand Factor activity (Ristocetin cofactor)
• Factor VIII
• Factor IX
• Fibrinogen

D-dimer is also sometimes added. Other laboratory evaluations may also include general screening testing such as a complete metabolic profile, uric acid and lactate dehydrogenase.

Questions for Further Discussion
1. List common congenital platelet problems. A review can be found here and here
2. What are the different types of von Willebrand disease? A review can be found here
3. What are some of the presentations of non-accidental trauma and neglect? A review can be found here

Related Cases

Disease: Bruises

Symptom/Presentation: Bleeding and Bruising

Specialty: Hematology

Age: Teenager

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: Bruises

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

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Akintoye SO, Mupparapu M. Clinical Evaluation and Anatomic Variation of the Oral Cavity. Dermatologic Clinics. 2020;38(4):399-411. doi:10.1016/j.det.2020.05.001

Patel B, Butterfield R. Common skin and bleeding disorders that can potentially masquerade as child abuse. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2015;169(4):328-336. doi:10.1002/ajmg.c.31462

Shah SN, Fong H fai, Haney SB, Harper NS, Pierce MC, Neuman MI. Has This Child Experienced Physical Abuse?: The Rational Clinical Examination Systematic Review. JAMA. 2025;334(2):160. doi:10.1001/jama.2025.2216

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Date
January 26, 2026

Patient Presentation
A 20-month-old male came to clinic for a febrile illness. He started to have a fever 36 hours ago up to 101.8° that responded to antipyretics. He was fussy and not drinking as well. There was some mild rhinorrhea but that had been present off and on as he had 2 older siblings and attended childcare. His mother denied any cough, obvious pain, rash, nausea, emesis, diarrhea or constipation. She said that his urine seemed more concentrated but was not frankly malodorous.

The past medical history revealed a history of grade I vesicoureteral reflux (VUR) that was being monitored by urology and which had improved from grade II that was diagnosed around birth. He was not on prophylactic antibiotics. He had not had any urinary tract infections diagnosed in the past when he had catheterized urine specimens for febrile illnesses. The family history was positive for his older brother with grade III VUR.

The pertinent physical exam showed a happy appearing toddler who was afebrile, had normal vital signs and growth parameters. His examination showed mild rhinorrhea.

The diagnosis of a toddler with likely viral illness was made, but because of the history, urology recommended to continue to perform urinalysis and culture with febrile illnesses. His mother agreed to the urine catheterization saying, “With his brother maybe needing surgery, I would rather do the cath and know if we need to give him antibiotics or do something else.” The laboratory evaluation of the urinalysis showed no signs of urinary tract infection and his culture eventually returned with no growth of pathogens.

Discussion
Vesicoureteral reflux (VUR) occurs when urine ascends from the bladder into the ureter. Primary VUR is the most common congenital anomaly of the urinary tract with an incidence of ~1%. Causes are abnormalities of the anatomic and/or physiological functions of the urinary collecting system. Abnormal reflux can cause serious problems including renal scaring or chronic kidney disease. Secondary VUR usually develops because of increased bladder pressure (e.g. posterior urethral valves, meatal stenosis, neurogenic bladder, etc.) or surgical procedures. VUR can also be transient such as bladder infections or bladder bowel dysfunction.

VUR is most commonly identified after a urinary tract infection (UTI), for follow-up of a previously diagnosed urogenital anomaly or screening of a sibling. UTIs are the most common presentation. Professional consensus recommends that males with first UTI should be evaluated for congenital anomalies of the urinary system and VUR. For females, some will also recommend this for first UTIs especially if there are risk factors for possible congenital anomalies or VUR, and it is recommended for recurrent UTIs. For most ages, males have a higher risk of VUR than females when presenting with a febrile UTI. Evaluation usually is renal ultrasound and may include voiding cystourethrogram (VCUG) or other studies.

Prenatal ultrasound often will identify hydronephrosis. This often resolves by birth or soon afterwards, but may identify continued VUR that needs monitoring or intervention. Resolution is more likely with younger ages (<1 year), lower grade of reflux, and asymptomatic presentation (i.e. prenatal hydronephrosis or sibling with VUR). Resolution for grades I-II are up to 80% but only 30-50% for grades III-IV during follow-up for 4-5 years. As noted, higher grades may not resolve and may require intervention to improve functional drainage and decrease the risk of renal scarring. Renal scarring is more likely in males, after repeated febrile UTIs and higher VUR grade.

VUR is graded based on the reflux into:

• I – non-dilated ureter
• II – non-dilated renal pelvis and calyces
• III – dilated renal pelvis and calyces
• IV – dilated renal pelvis and calyces with moderate ureteral tortuosity and fornices’ blunting
• V – gross dilation of renal pelvis and calyces with severe ureteral tortuosity and loss of papillary impressions

Examples of VUR on VCUG can be found here.

Learning Point
The risk for VUR in a sibling or child of a known VUR patient is high. The European Association of Urology noted that “[s]iblings of children with VUR had a 27.4% (3-51%) risk of also having VUR, whereas the offspring of parents with VUR had a higher incidence of 35.7% (21.2-61.4%).” Another study cites rates of 32% for siblings and 66% for parents. They also cite that “…VUR in siblings revealed that 52% had resolution of reflux after 18 months of followup, with yearly resolution rates of 28%.”

Questions for Further Discussion
1. What are potential complications of acute pyelonephritis? A review can be found here
2. What are causes of gross hematuria? A review can be found here
3. What are the most common organisms causing UTI in neonates, toddlers, school age children and teenagers?

Related Cases

Disease: Viral Infections | Vesicoureteral Reflux | Kidney Diseases

Symptom/Presentation: Fever and Fever of Unknown Origin | Urine

Specialty: Infectious Diseases | Nephrology / Urology

Age: Toddler

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 these topics: Ureteral Disorders and Urinary Tract Infections.

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

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Mattoo TK, Mohammad D. Primary Vesicoureteral Reflux and Renal Scarring. Pediatric Clinics of North America. 2022;69(6):1115-1129. doi:10.1016/j.pcl.2022.07.007

Hari P, Meena J, Kumar M, et al. Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux. Pediatric Nephrology. 2024;39(5):1639-1668. doi:10.1007/s00467-023-06173-9

Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children – ScienceDirect. Accessed October 6, 2025. https://www-sciencedirect-com.proxy.lib.uiowa.edu/science/article/pii/S0302283823032980?ref=pdf_download&fr=RR-9&rr=98a632a73b77accf

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa