Learning Collaboratory

If you are a Resident, Fellow, or Attending Physician practicing pediatrics – or if you are a Health Care Provider practicing pediatrics – you may participate in the Learning Collaboratory. Send us your comments or questions about specific cases posted on PediatricEducation.org by filling out the Question Form.

Answers to comments or questions about specific cases on PediatricEducation.org are posted here, in reverse chronological order.

Monday December 31, 2007 – How Long Does Immunity Last After Routine Childhood Immunization with Pertussis Vaccine?

N.C. from Egypt writes:
“The points you discussed on pertussis are very important, as nowadays we usually ignore it in our differential diagnosis in a child presenting with cough, unless there is a history of contact.”

I agree!

Monday October 15, 2007 – What Causes Heart Failure?

G.L. a pediatric cardiologist makes two comments:
1. “Congestive heart failure [CHF] may have ??? a myocarditis or dilated cardiomyopathy phase and supraventricular tachycardia [SVT] despite the biopsy being negative.”

2. “Beta Blockers are not used for CHF in [pediatrics] but are in adults because cardiac output is more rate dependant in kids and especially infants.”

1. It is possible that with this patient there was a component of myocarditis which caused an atrial ectopic tachycardia, and that myocarditis was not found on the biopsy.

2. The cardiologist is correct about the beta blocker in general but they are used in certain pediatric cases. Children with CHF are usually treated with a digoxin/furoxemide combination or an ionotropic agent/ diuretic regimen.

These points have been clarified in the case.

Monday September 3, 2007 – What Should I Order for An Immune Workup?

M.B., a family physician from the United States asks: “Did this child have history of pneumoccal immunizations?”

All of the patients written about in PediatricEducation.org are real patients. We change various information to protect identities and omit some information for clarity.
This patient most likely did not have pneumococcus vaccine because he was seen before this vaccine was given as part of the standard schedule for infants in the United States.
Additionally, this child was not known to have an underlying problem that would have indicated a need to give the enhanced pneumococcal vaccine that was available at that time.

An abbreviated history of Pneumococcus vaccine licensure includes:
1977 – Pneumococcus vaccine (14-valent) first licensed
1983 – Enhanced pneumococcus vaccines (23-valent) licensed (replaces 14-valent vaccine)
2000 – Conjugated pneumococcus vaccine (7-valent) licensed

Dr. M.B. also pointed out something to remember: “??? if an autopsy is considered important, many state medical examiners will perform them based on protecting public health.”

To Learn More
To see a history of vaccine licensure, review “I Don’t Want a New Vaccine for My Child.” Available from the Internet at http://www.pediatriceducation.org/2007/06/11

Monday November 27, 2006 – How Common are Latent and Active Tuberculosis Cases Identified Among Contacts?

M.K. from Australia writes: “I noticed you used tuberculin skin testing to diagnose latent tuberculosis infection. I thought tuberculin skin testing was not much value in this test. Maybe gamma interferon blood testing would be more specific and sensitive?”

Gamma interferon blood testing has been available since 2004 in the US. There are two tests available QuantiFERON-TB (QFT) and QuantiFERON-TB GOLD (QFTG) and they measure interferon release by sensitized lymphocytes when they are exposed to Mycobacterium tuberculosis antigens.

Advantages of the tests include better sensitivity and sensitivity for latent tuberculosis infection, one patient visit, less subjective measurement, unaffected by prior BCG vaccination and repeated testing can be done because there no immune boosting occurs.

The disadvantages include requiring a blood draw for the sample, samples must be processed within 12 hours of collection, the test may not be offered by many laboratories and it also costs $80-100/test.

The current recommendations of the American Academy of Pediatrics do not recommend using this testing and it is not recommended by the Centers for Disease Control for children under 17 years of age.

To Learn More
Campos-Outcalt D. When, and when not, to use the interferon-gamma TB blood test. J Fam Pract. 2005;54:10. Available from the Internet at http://www.jfponline.com/Pages.asp?AID=2769&UID= (cited 11/29/06).

Tuesday July 11, 2006 – Can I Use This Medicine When I am Breastfeeding?

S.T., an attending physician asks “What drugs are contraindicated in breastfeeding?”

As each patient and the circumstances are uniquely individual, it is difficult to answer this question. Many drugs do pass into the breast milk but formal studies on the consequences for the infant and/or the mother may be lacking. The risks of not giving a medication to a mother must also be assessed (e.g. untreated maternal depression). Alternative medications may or may not be available with their own risks and benefits and these also need to be considered. Therefore, it is best to consult a current pharmacology resources such as LactMed Drug and Lactation Database (http://www.toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT) described in this case.

To Learn More
An extensive listing of drugs excreted in breast milk can be found at: Physicians’ Desk Reference 60th edit. Thomson PDR. Montvale, NJ. 2006: 3537.

Monday June 5, 2006 – What Can I Do About All These Mosquito Bites?

M. D. writes:
“Common mosquito bites can be effectively and safely treated with ice. The swelling begins to recede almost immediately upon contact, and the itching is instantly alleviated. The sooner the ice is applied the less time it will need to be applied. In an older child or adult this means that the itch can be treated even before the swelling becomes apparent. However older stubborn bites will respond to ice as well if cooled long enough.

Closed water-filled plastic cubes or cooling elements work nicely because they don’t drip. They can be held with potholders. Ice frozen in popsicle forms is also handy as it can be held by the sticks.

No adverse reactions to this treatment are known. Of course common sense should be employed and the child should not be exposed to risk of hypothermia.”

Great reminder!

Monday October 10, 2005 – Why Am I So Short?

S.R., an attending pediatrician comments: “Some points does not make sense, regarding constitutional delay. On reviewing the growth chart it appears that the patient is not following his curve and has crossed down the percentile twice suggesting that he grew at subnormal growth velocity at least twice which argues against simple constitutional delay. Second having delayed bone age does not automatically make the diagnosis of constitutional delay unless other causes of attenuated growth looked for and ruled out.”

Each of the cases in PediatricEducation.org are real cases that we have been involved with or know about in some manner. Elements are changed for patient privacy. The information presented is what was available for this patient. Dr. S.R. appears to believe that this patient needed a more extensive evaluation. What do others believe?

Monday, April 11, 2005 – Is this Kawasaki Disease?

J.G., an attending physician asks: “I have been told in the past that the conjunctival injection is not only bulbar and nonpurulent but also does not extend to the limbus/edge of the iris, leaving a clear/uninvolved area around the iris. Is this finding consistent or is it more variable and if consistent can it be used to help diagnose Kawasaki Disease along with the other findings or lack thereof?”

According to the recent article on Diagnosis, Treatment and Long-term Management of Kawasaki Disease by Newburger et.al. In Kawasaki Disease, “the bilateral conjunctival injection usually begins shortly after the onset of fever. It typically involves the bulbar conjunctivae (sparing the limbus, an avascular zone around the iris) much more often than the palpebral or tarsal conjunctivae; is not associated with an exudate, conjunctival edema or corneal ulceration; and usually is painless. Mild acute iridocyclitis or anterior uveitis may be noted by slit lamp; it resolves rapidly and rarely is associated with photophobia or eye pain.”

“Characteristics suggesting disease other than Kawasaki disease include exudative conjunctivitis, exudative pharyngitis, discrete intraoral lesions, bullous or vesicular rash, or generalized adenopathy.”

To Learn More
Newberger JW, Takahasi M, Gerber MA, et. al. Diagnosis, Treatment and Long-term Management of Kawasaki Disease. Circulation 2004;110:2747-2771. Available from the Internet at: Available from the Internet at: http://circ.ahajournals.org/cgi/content/full/110/17/2747 (cited 4/18/05).