Fall Break

PediatricEducation.org is taking a fall break. The next case will be published in on October 10th.

In the meantime, why don’t you look at a Random Case from the top of the page? You can also look at the different Differential Diagnoses, Symptom and Disease lists too.

We appreciate your patronage,
Donna D’Alessandro and Michael D’Alessandro, curators.

What Are Treatments for Panic Disorder?

Patient Presentation
A 17-year-old male came to clinic for difficulty eating for the past day. He was known to have generalized anxiety and specific panic attacks around food that he was being treated for with psychotherapy and selective serotonin reuptake inhibitors. He had not had a panic attack for many months. The day before he was at a picnic and choked on some potato salad while he had been talking and laughing with friends. He choked, coughed and then had emesis, he had feelings of anxiety and being out of control immediately afterwards. He noted he had tachycardia, tachypnea and sweating at that time. He walked away from the group and did deep breathing which helped but didn’t stop the problem. When he was calmer he drove himself home and since then has continued to have perseverative thoughts about the incident and is afraid to eat solid food. He had been drinking. He slept poorly. He stated that he knows that this is not rational, but he has been unable to calm his mind about it. The review of systems was negative.

The pertinent physical exam revealed a healthy male with slight tachycardia at 106 beats/minute, respiratory rate of 24/minute and normal blood pressure. He seemed anxious overall and seemed most anxious that he felt he should be able to control his feelings better than he was able to. His physical was normal.

The diagnosis of panic attack after a precipitating event was made. The pediatrician discussed options with the teenager. He decided that he was going to call his therapist and see if the therapist could see him or talk by phone or telemedicine the same day. He decided he didn’t want to try a benzodiazepine medication, but said that in the past he had used diphenhydramine for allergies which helped make him sleepy. “I actually already feel better just being checked out. I’m going to call my therapist, and I’m tired now because I didn’t sleep very well. I think I will be better after I get some sleep. My sister and parents are also really helpful, so I know I’ll be better,” he stated. A safety plan and reasons to followup were discussed.

Discussion
Panic disorder is “…one of the anxiety disorders and is characterized by repeated, unexpected panic attacks, involving physical symptoms such as racing heart, dizziness and chest pains, along with a fear of recurring attacks and changing behaviors to avoid further attacks.” It has both physical manifestations and mental ones including extreme fear such as mortal fear, loss of control and fear of alienation.
It is most common in teenagers aged 15-19 and is very common with about 1% of teens experiencing attacks. A study of college students in multiple countries found a lifetime prevalence of 5%.

A review of generalized anxiety disorder and an anxiety differential diagnosis can be found here.

Learning Point
Treatment for patients with panic attack is often multimodal with behavior and medication therapy used singly or in combination. Behavioral therapy to help the patient and family to understand the problem, recognize the triggers and increase coping skills to manage their symptoms are the basics. Cognitive behavioral therapy (CBT) has been used to treat patients with success. Relaxation methods often are very helpful to pediatric aged patients to manage their symptoms. Supportive school and home environments can offer consistency and reassurance can also help. Appropriate physical activity and exercise also can help patients with anxiety.

Selective serotonin reuptake inhibitors (SSRI) are usually the first type of medications used in addition to behavior therapy. SSRIs do carry a “black box warning” for a potential increase in suicidal ideation. Therefore this must be discussed with the patient and family along with a safety plan and close monitoring of the patient. Other medication options include benzodiazepines, selective serotonin and norepinephrine reuptake inhhibitors, and tricyclic antidepressants. Patients are usually treated with medication for at least 6-12 months before slow tapering of the medication.

For patients who are acutely having a panic attack, acknowledging the problem, calming talking with them, trying to decrease the ambient stimulation, and helping them to slow their breathing giving them time and space to help themselves often will be enough to bring some relief. Helping to fulfill other physiological needs such as hunger, thirst, sleep, too cold/too warm, etc also decreases the stress for the patient. For some patients a short-acting benzodiazepine such as lorazepam is sometimes used one time. Acute followup and counseling should be arranged for patients before they leave the emergency room or clinic.

Questions for Further Discussion
1. What is the difference between a fear and phobia? A review can be found here
2. What mental health resources are available in your community?

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: Panic Disorder

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.

Wang Z, Whiteside SPH, Sim L, et al. Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders. JAMA Pediatr. 2017;171(11):1049-1056. doi:10.1001/jamapediatrics.2017.3036

Auerbach RP, Mortier P, Bruffaerts R, et al. The WHO World Mental Health Surveys International College Student Project: Prevalence and Distribution of Mental Disorders. J Abnorm Psychol. 2018;127(7):623-638. doi:10.1037/abn0000362

Strohle A, Gensichen J, Domschke K. The Diagnosis and Treatment of Anxiety Disorders. Dtsch Arztebl Int. 2018;155(37):611-620. doi:10.3238/arztebl.2018.0611

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

When is Bruxism Bad?

Patient Presentation
An 11-year-old female came to clinic for her junior high health examination. She was well and had no concerns. She noted that she was going to get braces soon. Her mother said, “Yeah the dentist also started her wearing a mouth guard at night because she was grinding her teeth and was wearing away her teeth. The orthodontist thinks that some of it will be better with aligning her teeth better.” She denied any problems otherwise with sleeping including no snoring, and no headache, mouth or neck pain. She and others did not notice the bruxism during the day. The past medical history revealed a broken arm from a playground fall.

The pertinent physical exam revealed a healthy female with normal growth parameters, who did have noticeable wearing on her molars and many malpositioned teeth. The diagnosis of a healthy female with bruxism was made. “I don’t have anything else to offer you. It looks like you are otherwise healthy so keep wearing the mouthguard and do what your dentist and orthodontist say to do,” the pediatrician recommended.

Discussion
Bruxism “is a masticatory muscle activity that may occur during sleep ([sleep bruxism, SB] characterized as rhythmic or non-rhythmic) and/or wakefulness ([awake bruxism, AB] characterized as repetitive or sustained tooth contact and/or by bracing or thrusting the mandible.)” Bruxism was first described in 1907. Bruxism studies are quite variable in their results given the lack of standardized diagnostic methods.

Patients or family members will often report tooth grinding noises, and on physical examination there will be abnormal tooth wear, tooth mobility, hypertrophy of the masseter muscles and other problems such as fatigue, pain or discomfort in the mouth/jaw and/or headache. Tooth grinding noises by themselves is not necessarily a problem. Usually minimal criteria for SB include “…tooth grinding or clenching while asleep and one or more of the following: abnormally worn teeth, bruxism-related sounds, and mandible muscle discomfort.” Prevalence in adults for AB = 22-30%, SB = 1-15%, and in the pediatric population is 3-49%. Peak age is 10-14 years.

Factors that seem to be associated with SB include second-hand smoke, caffeine, tobacco and alcohol use, gastroesophageal acidification and some psychotropic medications (including serotonin reupdate inhibitors, antipsychotics, norepinephrine reuptake inhibitors, amphetamines, and Ecstasy).

Bruxism can also be considered a sleep-related movement disorder and can be associated with sleep disturbances such as obstructive sleep apnea, restless leg syndrome, rapid-eye movement disorders and mandibular myoclonus. Bruxism can have direct problems such as pathological tooth destruction, dental procedure failure, temporomandibular joint dysfunction [commonly in teens], mandibular joint movement problems and headaches.

Etiology is probably multifactorial but some data suggest potential risk factors including anxiety and stress, personality traits, genetic predisposition, socioeconomic and sleep problems. SB may offer some benefit by protecting the airway or stimulating saliva production. Gastroesophageal reflux may also stimulate saliva production and therefore SB may be partially protective as well.

Learning Point
Bruxism is probably a continuation from no bruxism to some that is not clinically significant and thus not needing treatment to some that is clinically significant and/or severe and needs treatment. Treatment also has a range of options, from patient and family education to occlusal appliances to more substantive treatments. Those can include physiotherapy, psychotherapy including biofeedback, medications such as benzodiazepines, and surgical treatment. Good sleep hygiene is good for any patient. In addition to dentistry, other consultants may be necessary such as sleep medicine, psychology and otorhinolaryngology. Per one study their decision making included the following questions:

  • Is the bruxism frequent and is the tooth wear severe? Needs dental evaluation
  • Is the patient anxious? Needs psychology and psychiatry expertise
  • Does the patient show signs of ventilatory disorders (snoring, oral ventilation, dark circles, daytime sleepiness, etc.)? Needs otolaryngology and pulmonary expertise. Sleep medicine is also a consideration.
  • Does the patient present with associated sleep disorders such as night terrors or agitation? Needs primary care and developmental expertise

Questions for Further Discussion
1. What are common parasomnias? A review can be found here
2. What causes temporomandidibular pain? A review can be found here
3. What causes jaw pain? A review can be found here

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: Tooth Disorders and Sleep Disorders.

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.

Melo G, Duarte J, Pauletto P, et al. Bruxism: An umbrella review of systematic reviews. J Oral Rehabil. 2019;46(7):666-690. doi:10.1111/joor.12801

Bulanda S, Ilczuk-Ryputa D, Nitecka-Buchta A, Nowak Z, Baron S, Postek-Stefanska L. Sleep Bruxism in Children: Etiology, Diagnosis, and Treatment – A Literature Review. Int J Environ Res Public Health. 2021;18(18):9544. doi:10.3390/ijerph18189544

Casazza E, Giraudeau A, Payet A, Orthlieb JD, Camoin A. Management of idiopathic sleep bruxism in children and adolescents: A systematic review of the literature. Arch Pediatr. 2022;29(1):12-20. doi:10.1016/j.arcped.2021.11.014

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

How Long Does A Cephalohematoma Take to Resolve?

Patient Presentation
A 14-day-old female came to clinic for her routine infant followup. Her experienced parents had no questions other than when her small cephalohematoma should resolve. The past medical history showed a term infant at 3280 grams birthweight born by vaginal delivery, who was breastfeeding and had no significant jaundice.

The pertinent physical exam revealed a vigorous infant with a weight of 3340 grams, head circumference and length were 50%. She had an approximately 2 cm elevated firm mass on her right parietal skull that did not cross any suture line. The rest of her examination was normal.

The diagnosis of a healthy infant with a small cephalohematoma was made. The resident reassured the family that it should resolve in a few weeks, but when staffing said she didn’t know the exact answer. The attending said he didn’t know exactly either but in his experience it was just a few weeks but they could ossify which then takes longer to resolve. He said he had never seen any intervention done for them. The patient’s clinical course at followup at 2 months of age, showed the cephalohematoma to be resolved.

Discussion
Cephalomatomas occur relatively commonly in 0.2-3% of newborn infants. They are blood collections in the subperiosteal skull bones, usually in the parietal area. They are usually unilateral but can be bilateral. They do not transilluminate. They are felt to be caused by pressure or other trauma and occur in vaginal and cesarean deliveries, with presumed periosteal disruption leading to externally located bleeding (not on the brain side of the bone). The blood fills the space with some pressure building up and the blood acts to tamponade itself. The blood coagulates, slowly organizes and is reabsorbed. If reabsorption is delayed then ossification can occur but these also usually reabsorb but more slowly.

Increased risks include prolonged overall or second stage of labor, macrosomia, abnormal fetal position, multiple gestation, weak uterine contractions and instrumented delivery such as vacuum extractor or forceps. Larger cephalohematomas are more likely to have ossification. The differential diagnosis includes caput succedaneum, vacuum caput, subgaleal hematoma, congenital abnormalities such as leptomingeal cyst or meningocoeles. Persistent bleeding could also be an indication of a hemophilia. Underlying skull fracture can occur but is unlikely. If there is more significant bleeding, then hyperbilirubinemia may be accentuated.

Treatment is usually reassurance for families and watchful waiting. Compressive dressings can be applied around birth. Aspiration or other surgical techniques are usually not necessary and have risks of infection, anesthesia, potential surgical complications and necessary followup care. Usual indications for surgery include cosmetic deformities, craniosynostosis or confirmed restricted brain growth. Monitoring of infants is always recommended.

Learning Point
Reports of resolution timing usually say something like “a few weeks.” One case series of 94 infants with large (> 50 mm) cephalohematomas found 76.6% had resolved at 4 week examination and 12.7% more (total = 89.4%) had resolved by 8 week examination. The additional 9.6% became ossified but again resolved completely or partially by 1 year.

Another study of ossified cephalohematomas in their discussion state that “After ossification, cephalohematoma may still get absorbed slowly and most often disappears over 3-6 months.”

Questions for Further Discussion
1. What causes macrocephaly? A review can be found here

2. How is caput different than cephalohematoma?
3. What are indications for neonatology consultations?

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: Child Birth Problems

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.

Guclu B, Yalcinkaya U, Kazanci B, Adilay U, Ekici MA. Diagnosis and treatment of ossified cephalohematoma. J Craniofac Surg. 2012;23(5):e505-507. doi:10.1097/SCS.0b013e318266893c

Ucer M, Tacyildiz AE, Aydin I, Akkoyun Kayran N, Isok S. Observational Case Analysis of Neonates With Large Cephalohematoma. Cureus. 13(4):e14415. doi:10.7759/cureus.14415

Raines DA, Krawiec C, Jain S. Cephalohematoma. In: StatPearls. StatPearls Publishing; 2022. Accessed June 27, 2022. http://www.ncbi.nlm.nih.gov/books/NBK470192/

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