Enjoying the Spring

PediatricEducation.org is taking a short Spring break. The next case will be published in on March 29. In the meantime, please take a look at the different Differential Diagnoses, Symptom and Disease listed at the top of the page. Maybe enjoy some cool spring air outside as well.

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What Are Generalized Anxiety Disorder Treatment Components?

Patient Presentation
A 13-year-old male came to clinic for his well child examination. His mother gave a history of increasing stomachache at school that was also occurring at home. He had it several times a week and had missed a few days of school over the past several months because of it. “I thought it was just a sensitive stomach or constipation but that doesn’t seem to be the problem,” she noted. The stomachache wasn’t related to food, exercise, and doesn’t awaken him at night. He had no emesis, nausea or diarrhea. His bowel movements were usually every day to every other day and were soft. “He’s a nervous kid. Always has been. It got worse this fall when he started 7th grade. He says that other kids don’t really bother him, but he is worried they might. His school work is okay, but he also worries about that. He worries about the weather especially if there is a storm or snow. I get worried about some of the same things, and I’ve tried to help him realize that these things happen to everyone, but don’t know how else to help him,” she went on. The patient confirmed the history and also noted that he had times where he had problems going to sleep because he kept worrying about something. He also endorsed some muscle tension from time to time. He said he would try to listen to music or do something active to try to take his mind off things that worried him.

The past medical history showed general complaints of abdominal pain or headache in the past. The family history was positive for anxiety and depression. The review of systems was negative for palpitations, syncope, seizures, tremors, etc.

The pertinent physical exam showed a well-appearing male with normal growth parameters. HEENT was normal including a normal thyroid examination. Heart, lungs, abdominal and neurological examinations were normal.

The diagnosis of a child with normal growth and chronic stomachaches along with anxiety was made. The physician discussed potential options with the family. The mother did not want to pursue medication treatment at this time, but both she and the patient were interested in him learning better coping skills. The patient’s clinical course after about 3 months of behavioral therapy showed him to be more confident, less worried and having fewer stomachaches. The family continued to decline medication and wanted to continue the behavioral therapy.

Discussion
Generalized anxiety disorder (GAD) is “…excessive anxiety and worry about a number of events and activities coupled with at least one physical symptom, which may include fatigue, poor concentration, restlessness, irritability, muscle tension, and sleep difficulties.” Other ways it presents to the primary care office may be abdominal pain, headache or heart palpitations, dizziness, syncope, numbness, trembling, paresthesia, memory loss, or urinary frequency. It has an estimated prevalence of 15% and is the second most common anxiety disorder in children after social anxiety disorder. GAD can commonly co-occur with attention deficit disorder, depression and other anxiety disorders (e.g. social anxiety or separation anxiety). There is a complex interaction between physical symptoms (including those with functional symptoms), pain (and especially pain threshold and how it is perceived) and the anxiety where one area can exacerbate the other. Anxiety itself is probably underdiagnosed because of these interactions. Anxiety in the adult population may have evidence of its beginning in childhood or adolescence.

History including psychosocial assessment and history of current stressors and/or current or past trauma can be very helpful along with appropriate anxiety screening tests for the appropriate age. Physical examination also helps with assesments for possible organic issues. Testing should be guided by the history and physical examination.

The differential diagnosis includes:

  • Mental health/psychological issues
    • Anxiety disorders including social anxiety, separation anxiety, panic disorders, fears
    • Attention deficit disorder
    • Depression including bipolar disorder
    • Developmental disorders
    • Learning disorders
    • Oppositional defiant disorder
    • Psychotic disorders
    • Psychosocial stressors – death, separation/divorce, financial problems, housing or food insecurity, environmental stressors, etc.
    • Trauma – past or ongoing including bullying
    • Substance abuse
  • Organic issues
    • Asthma
    • Cardiac arrhythmias
    • Hypoglycemia
    • Hyperthyroid
    • Pheochromocytoma
    • Seizure disorder
    • Substance use – caffeine, anti-asthmatics, antihistamines, antipsychotics, selective serotonin reuptake inhibitors (SSRI), steroids, and sympathomimetics
    • Toxins – lead

Learning Point
Treatment for patients with GAD is often multimodal with behavior and medication therapy used in combination based on research outcomes. 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. Components of CBT may include “…cognitive restructuring, problem-solving, relaxation training, modeling, contingency management, imaginal and in vivo exposure and relapse prevention.” Relaxation methods often are very helpful to pediatric aged patients to manage their symptoms. Appropriate physical activity and exercise also can help patients with anxiety. School and home environments which offer consistency and reassurance seem to be beneficial for patients.

Selective serotonin reuptake inhibitors (SSRI) and selective noradrenaline reuptake inhibitors (SNRI) are usually the first type of medications used in addition to behavior therapy. SSRIs can have increased anxiety side effects including nervousness and agitation. 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. SSRIs can take 4-8 weeks for clinical effect to be fully realized. Other medications can include antidepressants, and other medications have been used in adults but seem less commonly used in the pediatric age group.

Questions for Further Discussion
1. How do you differentiate fears and phobias? A review can be found here
2. What causes abdominal pain? A review can be found here
3. How common is post traumatic stress disorder? 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: Anxiety and Child Mental Health.

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.

Manassis K. Generalized anxiety disorder in the classroom. Child Adolesc Psychiatr Clin N Am. 2012;21(1):93-103, ix. doi:10.1016/j.chc.2011.08.010

Dillon-Naftolin E. Identification and Treatment of Generalized Anxiety Disorder in Children in Primary Care. Pediatr Ann. 2016;45(10):e349-e355. doi:10.3928/19382359-20160913-01

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

What Are the Causes of Secondary Amenorrhea?

Patient Presentation
A 12-year-old female came to clinic for her health maintenance examination. She and her mother were concerned because she had had irregular menses for 1 year. They had seemed to stop after she had begun training and during her cross-country season which she was currently participating in. She was eating a fairly well-balanced diet but both stated that with her changed schedule for practice she was now missing an afternoon snack. She denied any eating disorder behavior, liked the way her body looked and felt and denied any sexual activity.

The past medical history showed breast budding at her 10 year visit, menarche at 11 years, and she had had 6 menstruations since that time but none for ~6 weeks coinciding with her increased exercise. The review of systems was negative for hair or skin changes, elimination problems, bruising/bleeding, changes in her voice or increased muscle mass, and balance or neurological problems including no difficulty with mentation. She was doing well with her friends and in school. There were no behavior or sleep changes and her energy was good. She denied taking any medications.

The pertinent physical exam showed normal vital signs. Her height between years 10-12 years was at the 75%. At her 10 year examination her weight was 32.3 kg (at 50%), at 11 year visit it was 34.1 kg (between 25-50%) and her current weight was 37.2 kg (between 25-50% but close to 25%). Her mother thought that the patient was 5 pounds heavier before running (still between 25-50%) HEENT had no abnormalities in her oral cavity or thyroid masses. Skin and neurological examinations were normal as was the rest of her examination. She was Tanner stage III for breast and pubic hair. Her genitalia showed a pink intact hymen.

The diagnosis of a healthy female with irregular menses was made. Her history fit the chronology of normal anovulatory menstrual cycles, probably complicated by increased exercise and mild weight loss. Pregnancy, chronic disease or brain tumor seemed unlikely. The laboratory evaluation at that time included doing a complete blood count and lipid panel for her health maintenance examination. Thyroid testing was also ordered. All eventually returned normal. The patient’s clinical course revealed that the pediatrician recommended to increase her overall calories by increasing nutritious food by a small amount during meals and re-instituting one snack at night. “I think this is a combination of your body learning to have periods and the exercise. If you don’t have another period in 6 weeks I want you to call me,” the pediatrician recommended. Within the week she had a normal 4 day menstrual period.

Discussion
The first sign of puberty in females is breast budding (Tanner stage II) which normally occurs from 8-13 years. Menarche usually occurs within 2 years of breast budding occurring usually at Tanner stage III-IV breast development. Menarche occurs for most girls from 10-15 years. Most cycles range between 21-45 days.

Age > 13 years without acquisition of secondary sexual characteristics, > 15 years before menarche or 5 years after acquisition of secondary sexual characteristics or cycles longer than 45 days are indications for evaluation. After menarche is it not uncommon to have anovulatory cycles that are irregular but generally they still occur within 45 days.

Primary amenorrhea is the absence of menses. Secondary amenorrhea is defined as no menses for 3 or more cycles or irregular menses for 6 months or more after regular menses are established. Secondary amenorrhea occurs in about 2-5% of college women but is more common in certain populations such as dancers and distance runners (65-69%).

First characterized in 1992, female athlete triad (FAT) includes “…low energy availability, menstrual dysfunction, and low bone mineral density.” Prevalence is 1-14% with highest frequency in professional ballet dancers. The cause of menstrual dysfunction in FAT is functional hypothalamic amenorrhea (FHA). A review of FAT can be found here.

FHA is caused by suppression of the gonadotropin-releasing hormone pulsatility in an otherwise normal (anatomically and organically) hypothalamic-pituitary-ovarian axis. The most common causes for FHA are excessive stress, exercise, or weight loss (including eating disorders). There also is a genetic disposition. FHA is the most common cause of primary and secondary amenorrhea in adolescent girls. It accounts for ~25-35% of secondary amenorrhea in adolescents. It is considered a non-organic cause of secondary amenorrhea and is a diagnosis of exclusion. Generally, short-term there are few complications. But long-term there can be increased risk of cardiovascular disease, and low bone mineral abnormalities, breast and vaginal atrophy and sexual dysfunction and fertility problems. Bone density accrual is the greatest in the teenage years and requires calcium, Vitamin D and phosphorus but also requires regular exercise and estrogen for optimal mineralization. Interestingly, if weight loss is the cause, the patient usually will have resumption of menses at an average of 2 kg more than the weight she became amenorrheic at.

Learning Point
Common causes of secondary amenorrhea and initial evaluation for these causes include:

  • Pregnancy
    • Pregnancy test
  • Thyroid dysfunction
    • Thyroid test
  • Functional hypothalamic amenorrhea (FHA)
  • Polycystic ovarian syndrome
    • Follicle stimulating hormone and leuteinizing hormone to evaluate for ovarian insufficiency and/or failure
    • Testosterone and DHEA if signs of masculinization
  • Causes of primary amenorrhea
  • Chronic disease
    • CBC
    • Complete metabolic panel
    • Tissue transgulatminease
  • Hormone based contraceptives
  • Prolactinoma
    • MRI of pituitary
  • Turner’s syndrome or other genetic problem
    • Karyotype

Questions for Further Discussion
1. What causes primary amenorrhea?
2. What causes dysfunctional uterine bleeding? A review can be found here
3. What potential health problems are associated with polycystic ovarian syndrome? A review can be found here
4. What are potential complications of teenage pregnancy? 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 this topic: Menstruation

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.

Berz K, McCambridge T. Amenorrhea in the Female Athlete: What to Do and When to Worry. Pediatr Ann. 2016;45(3):e97-e102. doi:10.3928/00904481-20160210-03

Sophie Gibson ME, Fleming N, Zuijdwijk C, Dumont T. Where Have the Periods Gone? The Evaluation and Management of Functional Hypothalamic Amenorrhea. J Clin Res Pediatr Endocrinol. 2020;12(Suppl 1):18-27. doi:10.4274/jcrpe.galenos.2019.2019.S0178

Huhmann K. Menses Requires Energy: A Review of How Disordered Eating, Excessive Exercise, and High Stress Lead to Menstrual Irregularities. Clin Ther. 2020;42(3):401-407. doi:10.1016/j.clinthera.2020.01.016

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

Who Gets Pott’s Puffy Tumor?

Patient Presentation
A 13-year-old female was referred with a history of headache, fever and swelling of her forehead for 24 hours after a few day history of rhinorrhea and nasal congestion. She was seen by an outside emergency room, started on antibiotics and referred for surgical treatment after the original computed tomographic study showed a frontal bone abscess. The past medical history was positive for otitis media as a younger child, and strep throat in the past. The family history was non-contributory.

The pertinent physical exam showed an ill-appearing female with a temperature of 101.9F, pulse of 96/minute, respiration of 22/minute with a normal blood pressure and growth parameters. She had midline forehead swelling with tenderness of the area. There were no other masses on her head. She had bilateral eyelid edema, but her pupils were equal and reactive, with normal extra ocular movements. Her nose had copious rhinorrhea bilaterally that was also seen in the posterior pharynx. Tonsils were 2+ and symmetric as was the uvula. Her neck had full range of motion and there were shotty anterior cervical nodes. Neurological examination showed normal mentation but the patient was in some pain. She had normal cranial nerves and the rest of her neurological and general examination was normal.

The diagnosis of Pott’s puffy tumor was made. The radiologic evaluation is shown below. The patient’s clinical course over the next several days included surgical drainage and antibiotics. The patient was discharged home on day 8 with home antibiotics for a planned minimum of 6-8 weeks.

Case Image
Sagittal CT with contrast of the brain shows complete opacification of the frontal sinus due to sinusitus (above left) and erosion of the inferior wall of the frontal sinus (above right) along with soft tissue swelling anterior to the left orbit. Coronal and sagittal T1 MRI with contrast of the brain shows multiple oval low intensity lesions in the left subgaleal tissues which are subcutaneous abscesses and multiple enhancing fluid collections in the subdural space along both cerebral convexities and the falx in the midline which is subdural empyema.

Discussion
Pott’s puffy tumor (PPT) was first described by Sir Percivall Pott in 1775 and who also described other orthopaedic and oncological diseases subsequently named for him. “It is a subperiosteal abscess of the anterior wall of the frontal sinus associated with underlying frontal osteomyelitis.” The tender edema and swelling of the forehead is the sign of PPT. Associated fever, headache, and rhinorrhea along with similar problems such as postnasal drip or nasal congestion are common. Associated ophthalmological problems include peri-orbital or eyelid edema and/or preseptal cellulitis. Ptosis and diplopia have also occurred. In a study of PPT ophthalmological complications, 72% of patients with ophthalmological problems also have intracranial complications.

In a 2020 review of the literature in children identified 93 cases. Sinusitis (79%) was the main cause with head trauma (8.7%) being another major cause. Other causes not discussed in this review include dental infections, surgical complications, substance abuse, mastoiditis, and fibrous dysplasia. The pathogens were often not identified (presumably because of pretreatment with antibiotics) but often had multiple organisms. Of single organisms, Streptococcus and Staphlococcus predominated. Epidural abscess (47%), subdural abscess (25%) and brain abscess (12%) were the most common intracranial complications, but cerebritis, fistula, pneumocephalus and superior sagittal sinus thrombosis also occurred.

The PPT infection is spread directly or hematogenously. “Direct extension…through posterior wall causing intracranial pathology, through the anterior wall results in in subperiosteal abscess, and/or through the inferior wall with orbital complications.” Septic emboli are believed to spread hematogenously through the thin walled diploic veins that drain the frontal sinuses and which “…communicate with the dural venous plexus and periosteum of the periorbital and cranial spaces.” Evaluation with radiologic imaging such as computed tomography or magnetic resonance imaging helps with diagnosis, determining the extent of the infection and complications and with surgical planning. Although prolonged antibiotic courses are important for management, surgical intervention to drain the abscess and debride the tissues such as bone and granulation tissue are the mainstay. Neurosurgical intervention for treatment of intracranial pathology when present is also a mainstay of management.

Learning Point
PPT occurs in all ages and is rarer in the antibiotic era but it appears that there are more cases being reported recently. There is a higher incidence in adolescence. In the 2020 review discussed above, the age ranged from 7 weeks to 19 years. Mean age was 11.94 years. 70% were male and 30% were female.

The review authors explain that the increased incidence during adolescence is probably due to anatomy as the diploic veins have increased blood flow, the frontal sinuses and bone-marrow spaces are less tight in adolescents compared with adults and the pneumatization of the frontal sinuses is finally finished by around 14-15 years of age.

Questions for Further Discussion
1. Explain the differences between brain, subdural and epidural abscesses?
2. Name some conditions that warrant emergency treatment by an otolaryngologist?

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: Abscess

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.

Parida PK, Surianarayanan G, Ganeshan S, Saxena SK. Pott’s puffy tumor in pediatric age group: a retrospective study. Int J Pediatr Otorhinolaryngol. 2012;76(9):1274-1277. doi:10.1016/j.ijporl.2012.05.018

Nisa L, Landis BN, Giger R. Orbital involvement in Pott’s puffy tumor: a systematic review of published cases. Am J Rhinol Allergy. 2012;26(2):e63-70. doi:10.2500/ajra.2012.26.3746

Koltsidopoulos P, Papageorgiou E, Skoulakis C. Pott’s puffy tumor in children: A review of the literature. Laryngoscope. 2020;130(1):225-231. doi:10.1002/lary.27757

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