What Causes Anal Itching?

Patient Presentation
A 7-year-old male came to clinic with a history of 2 days of significant anal itching. It was worse at night and he had seen “white stuff in my poop.” He and his mother denied any general skin problems but she noted, “he’s not always the best with cleaning himself after using the restroom.” There was no diarrhea, constipation or encopresis, changes in soaps, lotions, detergents, or other skin products. His diet was unchanged. He did attend a before and after school childcare program that had recently visited a local farm. There were no known ill contacts. The past medical history was non-contributory.

The pertinent physical exam revealed a healthy appearing boy with normal growth parameters and vital signs. His examination was normal except for general irritation around his anus and excoriation marks. No specific track or burrows were seen.

The diagnosis of probable pinworms was made. The patient was treated empirically with anti-helminths which his mother said had worked when he returned for his next health supervision visit.

Discussion
Pinworms are caused by the parasite Enterobius vermicularis. Humans are the only known reservoir and are infected by fecal-oral transmission of eggs or indirectly such as through contaminated clothing or bedding. It is commonly seen in children and can easily pass to family members, plus people can become easily reinfected. The incubation period is usually 1-2 months and eggs can survive outside humans for 2-3 weeks. Adult worms migrate at night from the anus to the perianal skin and vulvar areas causing anal or vulvar itching. The itching can cause sleep problems and scratching can cause secondary bacterial infection. The worms can exist in alternative locations such as the vagina, Bartholins glands and the urethra.

Diagnosis is by direct visualization of the adult worms about 2-3 hours after sleep or by the “scotch-tape test” where upon wakening the patient has clear cellophane tape applied to the perianal skin. The tape is then reviewed under a microscope to identify the adult worms. In many cases pinworms are treated presumptively because of the difficulty of obtaining specimens. Treatment is by antihelminthic agents such as mebendazole, albendazole, and pyrantel pamoate. Handwashing and laundering items in hot water helps to decrease transmission.

As pain and itch nerves travel together it can be difficult for patients to be able to distinguish between the two different sensations. Patients may complain of general genital area pain or specific anal pain and not pruritis. Significant pruritis can also cause pain too.

In younger children, soiling and hygiene issues along with skin conditions probably are the most common causes of anal pain and/or itch, but pinworms are quite common in this population and should be suspected.

Learning Point
Pruritis ani is “…an itch localised to the anus and peri-anal skin without a rash.” Peri-anal dermatosis is different and is caused by inflammatory diseases affected the anal area occurring with a rash. Given that patients often present with excoriation it can be difficult with some causes to tell these apart.

Causes of pruritis ani include:

  • Infection
    • Parasites – pinworms, scabies, swimmer’s itch
    • Bacterial – Streptococcus, Staphlococcus
    • Fungal – candida
    • Viral – pox and others
    • Sexually transmitted infections
  • Skin
    • Dermatitis – contact, atopic
    • Hidradenitis suppurative
    • Lichen sclerosis et atrophicus
    • Paget disease
    • Psoriasis
  • Soiling and hygiene
    • Encopresis
    • Diarrhea
    • Incontinence
    • Intertrigo
    • Hygiene products and medication – soaps, detergents, creams
    • Sweating
  • Anorectal problems
    • Anatomic abnormalities – rectal prolapse, hemorrhoid prolapse
    • Abscess
    • Fissures
    • Fistula
  • Diet
    • Acid containing products – citrus fruits, tomatoes
    • Beer
    • Caffeine containing products – chocolate, cola, coffee, tea
    • Milk
  • Systemic
    • Cancer – anal, rectal, colon, leukemia
    • Diabetes
    • Hepatic problem
    • Thyroid problems
  • Other
    • Drugs – chemotherapy
    • Psychological

Questions for Further Discussion
1. How often do you see parasites in your practice and what kinds?
2. How do you treat scabies?
3. What would be indications for consultation with a gastroenterologist for pruritis ani?

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 these topics: Anal Disorders and Pinworms.

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.

Stermer E, Sukhotnic I, Shaoul R. Pruritus ani: an approach to an itching condition. J Pediatr Gastroenterol Nutr. 2009;48(5):513-516. doi:10.1097/MPG.0b013e31818080c0

Abu-Asi MJ, White IR, McFadden JP, White JML. Patch testing is clinically important for patients with peri-anal dermatoses and pruritus ani. Contact Dermatitis. 2016;74(5):298-300. doi:10.1111/cod.12514

Ng NBH, Lin JB. Pruritus ani in a school age boy. BMJ. 2022;376:e067817. doi:10.1136/bmj-2021-067817

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

How Can a Consultation Be Made Better?

Patient Presentation
“You’ll want to look at this new patient who was added to your schedule this afternoon,” the nurse said to a pediatrician. It was a referral from an outside optometrist who had noted an optic nerve problem in an otherwise healthy school age child during a routine examination. The optometrist referred the patient for further medical evaluation including possible imaging. It was unclear if additional ophthalmological care had also been requested for the patient. The patient had not been seen within the health system and no additional information was available. The pediatrician contacted the on-call ophthalmologist who agreed that this was an eye problem first and potential medical problem second. The ophthalmologist contacted his colleagues in neuroophthalmology who worked the patient in that day.

Discussion
Most physicians go into medicine because they like people and want to help them and their families. Clinical patient care can also be fun, interesting, intellectually challenging and provide a creative outlet. All physicians will never know everything and need help with patient care problems that arise. That is when a patient should be referred for a consultation. Effective consultations have several important components which can be overlooked. When clear questions with background information are asked and the consultant provides specific clear recommendations answering the question but also planning for contingencies, the patient will get excellent care and both the requesting physician and the consultant will both learn from the consultation.

Patients and families should understand why the consultation is being requested so they can help the consultant and understand the consultant’s recommendations.

Learning Point
Some tips for effective consultations include:

  • What is the Question?
    • As the requesting physician (RP) actually phrase your question in the form of a question just like the television show Jeopardy! Don’t make the consultant guess what you want to know. Help the consultant to help you.
      • Ask “What antibiotics should be started and for how long should the treatment be? or What else should be considered in the differential diagnosis at this time and what additional evaluations should be considered? “
    • Give the consultant enough background information so they have a context with which to understand the question. Provide this in the consultation request in a letter, fax or the electronic medical record. Urgent or emergent requests should be done verbally.
      • “Rule out fracture” without saying where the pain is doesn’t help the radiologist who has to guess. Add the location, mechanism of injury etc.
      • Similarly, new cough and fever for 3 days is different than increasing cough and new fever after recent pneumonia for the radiologist and the infectious disease specialist.
  • What is the Timing?
    • When do you need to know the answer?
    • Is it emergent, urgent or elective?
    • Elective consultations can go through the usual request channels but urgent and especially emergent ones need to be verbally communicated directly.
    • Again tell the consultant directly what your expectations are. You may see it as emergent when the consultant sees it as urgent and decreases its priority in his/her workload.
    • The urgent consultation can become emergent too if the patient’s clinical situation changes.
  • Is It the Right Consultant?
    • It maybe unclear who would be the right consultant
      • A patient with a problem cough could see the allergist or the pulmonologist
      • A hand issue could be a hand surgeon, plastic surgeon or orthopaedic surgeon
    • As the RP ask if this is the right consultant, and the consultant should ask themselves if they are the right person too to answer the question.
    • RP and other providers who usually work outside a specific health system may not “know the system” and patients should be re-referred to the appropriate service if needed.
  • Who “Owns” the Patient or Problem after the Consultation?
    • The RP should be clear about if they still want to continue to be the “owner” of the patient and provide the overall management or if they would like the consultant to take over the care. “Owner” of the specific problem is similar. This should also be clearly stated in the consultation request.
    • Consultants should also be clear about who “owns” the patient or problem and not “steal” the patient or “ignore” the patient. “Stealing” or “ignoring” can be the RP’s viewpoint if “ownership” is not clear.
    • “Ownership” is fluid and may change as the patient’s clinical status changes too.
    • “Ownership” should be expressed to the patient so they understand who they should be communicating with regarding the “final say” in their care.
    • Whether the consultant “owns” the patient or problem, there should be appropriate periodic follow-up based on the patient’s clinical status.
  • What are the Recommendations?
    • As the RP, check the chart for elective recommendations. This is time efficient for the consultant and yourself.
    • Emergent and urgent matters should usually be discussed between the different people.
    • Communication between the RP and consultant is cheap and effective. It can provide information quickly, clarify questions and develop rapport and trust between the individuals.
    • Both the PP and consultant should be willing to say they don’t know the answer or only have part of the answer and seek additional help as needed.
  • Recommendations Should Be Brief and Specific
    • The consultant shouldn’t rewrite the entire medical record but should recap the salient points for the consultation and why the question is being asked.
    • The recommendations should be clear and specific so the recommendations can be understood and additional time isn’t needed for clarification. Reasons for the recommendations should be clear. The RPs are asking for help and therefore they do not have that expertise, so providing them with specific information will allow them to take great care of the patient and also learn at the same time.
  • Provide Contingency Plans
    • Patient’s clinical status changes and therefore provide information for when to talk with you again or a second line of care if the initial one doesn’t work for the patient.
    • Anticipating potential problems and communicating a plan is good for everyone.
  • Learning Goes Both Ways
    • Consultations are a great way to provide education to the RP about the problem. The RP usually will be interested in learning more, but they also will probably never be an expert in this problem like the consultant is. The RP will hopefully learn, and gain confidence in their clinical skills for the next time they face a similar problem. The RP should also be gracious in learning about their lack of knowledge for a problem. The consultant too can learn from the RP about their scope of practice, and their own clinical care expertise, and can use this for improving the specific recommendations they put into the consultation and their verbal discussions with RPs.
  • Use Your Manners and Be Gracious
      It should go unsaid that both the RP and the consultant are courteous, cordial and professional in their verbal and written communication.
      Legitimate disagreements occur and should be discussed verbally. The patient medical record is not the place for this type of discourse.
      “Pleases” and “Thank yous” go a long way to express your appreciation for the expertise and clinical skills of all the physicians involved.

Questions for Further Discussion
1. What other tips do you have for an effective consultation?

Related Cases

    Disease: Consultation and Referral | Communication

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.

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.

Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143(9):1753-1755.

Wilkie V, Ralphs A. The pressures on general practice. BMJ. 2016;353:i2580. doi:10.1136/bmj.i2580.

Kneebone R. Dissecting the consultation. The Lancet. 2019;393(10183):1795. doi:10.1016/S0140-6736(19)30898-0

Scaioli G, Schafer WLA, Boerma WGW, Spreeuwenberg PMM, Schellevis FG, Groenewegen PP. Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries. BMC Fam Pract. 2020;21(1):54. doi:10.1186/s12875-020-01124-x

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

Which Side Are the Organs On?

A 13-day-old male came to clinic for his health supervision visit.
He was breastfeeding, gaining weight well and was past his birth weight. He was breathing and eliminating without problems. The past medical history showed that the baby had had an abnormal prenatal ultrasound that was consistent with an abdominal lateralization defect. After delivery, the baby was well but taken to the neonatal intensive care nursery as a precaution and his evaluation showed a left sided liver with appropriate vasculature and a patent biliary system. His bowel also was rotated, and he had one spleen that was on the left side. He had normal position and anatomy in his thorax.

The pertinent physical exam showed a vigorous infant with no jaundice. His growth parameters were in the 50-75%. His cardiac examination was normal. On abdominal examination his liver was palpable on the left side. The diagnosis of a healthy infant with situs ambiguous was confirmed. “He looks and acts just like any other baby and they told he he may never have any problems. The surgeons are still deciding if anything should be done to prevent a problem though. We are supposed to see them in a couple of weeks,” the parents said. “I’m obviously happy to help you and will help the surgeons or any other specialist if they need it. As you know a lot of baby’s spit up, but with his different anatomy we’ll have to watch that more closely though,” remarked the pediatrician. “Yes, the surgeons are okay with the little baby spit up we’ve seen with our daughter, but if it is more forceful or occurs a lot or doesn’t look like the breastmilk, we’re supposed to call them and go to the emergency room,” the parents stated.

Discussion
Although externally vertebrates present with bilateral symmetry, this is not necessarily true internally for humans. Humans have a normal left-right asymmetry of their internal organs. For example, the right lung has 3 lobes and is slightly larger than the left lung with 2 lobes. The normal asymmetry is called situs solitus (SS). Complete reversal of the normal abdominal and thoracic organ positions is called situs inversus totalis (SIT). Variations on the laterality between situs solitus and SIT has been referred to by different names including situs ambiguous or heterotaxy. For this case, the term situs ambiguous (SA) will be used. Overall the incidence is 1 in 15,000 for all lateralization defects, with SIT being reported from 1 in 6,500-25,000. Laterality problems are associated with some specific syndromes and genes. Anatomic variations overall are very common and an illustrated atlas can be found here.

Learning Point
Such lateral anatomical variation may never cause any significant problems, but certainly has the potential to do so. Congenital heart defects, respiratory and hepatic problems are usually thought about first as they can cause acute life-threatening problems. However, patients may also have functional asplenia and increased risks of infection. Medical procedures may be more difficult to perform because of the differences in laterality, and imagine the surprise thoughts of the trauma surgeon who must also confront vast anatomical differences in an emergency situation.

SA like SIT is highly associated with cardiac defects. Congenital heart disease is associated with SS is only 0.6%, but is 3-9% for SIT and almost 80% for SA. SA also has many vascular anomalies especially those serving the hepatic system. Biliary atresia is also more common. Polysplenia or asplenia is also associated with SA.

SIT is associated with many different problems including congenital heart disease (e.g. complex and single lesions), gastrointestinal (e.g. biliary problems, anal atresia), respiratory system (e.g. bronchial dysplasia, primary ciliary disease), skeletal system (e.g. thoracic deformities, spinal deformities, polydactyly), urinary system (e.g. chronic kidney disease, uronephrosis, chronic kidney disease), and various others (e.g. dwarfism, cleft lip and palate, hernia, intellectual disability, precocious) among others. SIT is highly associated with various ciliopathies, a review of which can be found here.

Questions for Further Discussion
1. How often have you seen lateralization defects?
2. What is the general pediatrician’s role for patients with rare diseases? A review can be found here

Related Cases

    Disease: Situs Ambiguous | Anatomic Variation | Anatomy

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: Anatomy

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.

Knowles M, Zariwala M, Leigh M. Primary Ciliary Dyskinesia. Clin Chest Med. 2016;37(3):449-461. doi:10.1016/j.ccm.2016.04.008

Chen W, Guo Z, Qian L, Wang L. Comorbidities in situs inversus totalis: A hospital-based study. Birth Defects Research. 2020;112(5):418-426. doi:10.1002/bdr2.1652

Eitler K, Bibok A, Telkes G. Situs Inversus Totalis: A Clinical Review. Int J Gen Med. 2022;15:2437-2449. doi:10.2147/IJGM.S295444

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

When Should a Newborn Infant Start Tummy Time?

Patient Presentation
A 31-day-old, former 33 week premature infant was seen in the resident continuity clinic for his weekly follow-up. He had been born and monitored in the neonatal intensive care unit where he received pressure support ventilation for 9 days. He was weaned off all support and supplemental oxygen by 17 days and was discharged home. He had been gaining weight at 15-20 grams/day for the past 10 days. His mother knew from her last child that she was supposed to do “tummy time” with infants but wasn’t sure what to do because he was premature.

The pertinent physical exam showed a well appearing male whose weight was 2.876 kg, length was 47 cm and head circumference was 32 cm. All were approximately the 50th percentile. Neurologically, he still had primitive reflexes and these were somewhat exaggerated but appropriate. He would lift his head off the table.

The diagnosis of a 37 week infant who was a former 33 week premature infant was made. The pediatrician said that she was not specifically aware of any recommendations for tummy time for premature babies. “I see that you are putting him on your chest and he holds his head well. I would continue to do that. I think you could also try to put him on the floor on his tummy too and see how he does. No matter how old the infants are, if they have their tummies down, they need to be awake and watched at all times. You need to make sure he doesn’t put his head down too far and tries to collapse his airway. That is less likely as he is now older but you need to watch him closely when he is on his tummy. If you see any problems then move him on his back right away and we can talk about when to try again. Remember though when you go to place him to sleep he should always be laid on his back,” the pediatrician recommended.

Discussion
Tummy time (TT) is one of a newborn’s and young infant’s major physical activities. TT is when an infant is placed awake on a firm surface (such as a floor) in a prone position while supervised by an adult. This encourages the infant to elevate their head and push up with arms to elevate their upper torso. TT is encouraged to be done in short amounts of time several times a day and to increase the amount of time in this supervised position up to 30 minutes total per day. TT has been associated with gross motor movement and development and is a component of the World Health Organization’s and several other national movement guidelines. Data shows that only 30% of parents and 75% of child care professionals adhere to these guidelines though.

A systemic review of TT and infant health found that TT is associated with “gross motor and total development, a reduction in [obesity], prevention of brachycephaly, and the ability to move while prone, supine, crawling and rolling.”

Learning Point
The American Academy of Pediatrics’ 2022 technical report on infant sleep states about TT: “Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of positional plagiocephaly. Parents are encouraged to place the infant in tummy time while awake and supervised for short periods beginning soon after hospital discharge, increasing incrementally to at least 15 to 30 minutes total daily by 7 weeks of age.”

This author was not able to identify specific guidelines for premature infants and TT. Infants who had chest or other surgeries may have similar issues. One study of infants < 4 months old (and as young as 2 days) who had undergone cardiac surgery and who had been instructed to do TT, found improved motor skill outcomes.

Questions for Further Discussion
1. What physical activities do you recommend for different ages of children?
2. What do you recommend to help patients and families with obesity?
3. What are some of the special nutritional needs for premature infants?
4. What are infant sleeping guidelines for newborns?

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 these topics: Sudden Infant Death Syndrome and Infant and Newborn Development.

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.

Hewitt L, Stanley RM, Cliff D, Okely AD. Objective measurement of tummy time in infants (0-6 months): A validation study. PLoS One. 2019;14(2):e0210977. doi:10.1371/journal.pone.0210977

Hewitt L, Kerr E, Stanley RM, Okely AD. Tummy Time and Infant Health Outcomes: A Systematic Review. Pediatrics. 2020;145(6):e20192168. doi:10.1542/peds.2019-2168

Koren A, Kahn-D’angelo L, Reece SM, Gore R. Examining Childhood Obesity From Infancy: The Relationship Between Tummy Time, Infant BMI-z, Weight Gain, and Motor Development-An Exploratory Study. J Pediatr Health Care. 2019;33(1):80-91. doi:10.1016/j.pedhc.2018.06.006

Uzark K, Smith C, Yu S, et al. Evaluation of a “tummy time” intervention to improve motor skills in infants after cardiac surgery. Cardiology in the Young. Published online September 27, 2021:1-6. doi:10.1017/S1047951121003930

Moon RY, Carlin RF, Hand I, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME and THE COMMITTEE ON FETUS AND NEWBORN. Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics. 2022;150(1):e2022057991. doi:10.1542/peds.2022-057991

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