What Are Some Pediatric Oncological Emergencies?

Patient Presentation
An 8-year-old female came to the hospital ward with fever up to 101.3 F and neutropenia. She was in her maintenance phase of chemotherapy for acute lymphoblastic leukemia and had received her last chemotherapy 3 weeks previously. Despite using granulocyte stimulating medications, she had had several previous hospitalizations for fever and neutropenia and had responded to antibiotics and monitoring without additional complications. She did endorse some mild abdominal pain but no specific nausea, emesis or diarrhea. The review of systems was negative for respiratory problems, other pain, rash, neurological problems or musculoskeletal problems. She was tired, but parents said this was usually true around this time of her chemotherapy cycle. She had some mild mucositis and was being treated with her oral regimen. She was drinking fairly well and urinating well.

The pertinent physical exam showed a slightly pale and tired patient with normal vital signs including a normal blood pressure. Her weight was 24.1 kg (just below 50%) and down 500 grams from her last clinic visit. HEENT showed alopecia. Mild buccal and tongue ulcerations without obvious thrush. She had no other mucositis noted or obvious lymphadenopathy. Her abdominal exam revealed some mild periumbilical tenderness without guarding. There was no pain in McBurney’s point and no costovertebral angle or suprapubic tenderness. She had no obvious masses and no hepatosplenomegaly. Her bladder was not distended. The rest of her examination was normal.

The laboratory evaluation showed a hemoglobin of 10.3 g mg/dL, total neutrophil count of 485, platelets were 130 x 1000/mm2. Other laboratories were normal include electrolytes, liver function tests, amylase and lipase, uric acid and lactate dehydrogenase.

The diagnosis of fever and neutropenia was made. She was started on antibiotics. The senior resident reminded the interns to monitor her closely especially for abdominal pain. “I know that this looks like a usual fever and neutropenia admission, but you never know that. It could always be something else, so watch her belly tonight. If you aren’t sure, just call me. I’d rather hear about it than not,” she reminded them. The patient’s clinical course showed that her abdominal pain resolved and she was released on day 5 after 24 hours fever free and her hematological counts were increasing.

Discussion
Pediatric cancers in the US number about 12,000 per year. After injury, it is the second leading cause of death in children and adolescents. Cancer presentations vary widely, but often begin with non-specific symptoms that continue or progress depending on the location and tumor type. Patients can present with oncological emergencies especially if there are mechanical obstruction such as superior vena cava syndrome or cerebral herniation. More commonly are infections due to immunosuppression. Cancer treatment also causes its own myriad of problems that clinicians need to be aware of to diagnosis and treat, but again they can have insidious or non-specific presentations. Patients often present with a commonly anticipated problem such as fever and neutropenia or abdominal pain, but it may be a sign of something more emergent. Patients not acting right initially, or not responding to treatment as expected, may have another problem.

Learning Point
Pediatric oncological emergencies include:

  • Cardiovascular/Pulmonary
    • Pericardial effusion or tamponade
    • Hemoptysis
    • Infection
    • Pulmonary embolism
  • Gastrointestinal
    • Bowel obstruction or perforation
    • Infection – appendicitis, tyhilitis or neutropenic colitis
    • Intussception
    • Pancreatitis
  • Hematologic
    • Anemia
    • Bleeding
    • Disseminated intravascular coagulation
    • Hyperleukocytosis
    • Leukopenia
    • Thrombocytopenia
    • Thrombosis
    • Transfusion reactions
  • Infection
    • Fever and neutropenia
    • Infection – bacterial, fungus, viral, parasitic
    • Septic shock
  • Metabolic
    • Tumor lysis syndrome
    • Calcium, hypo- or hyper-
    • Phosphate, hyper-
    • Potassium, hyper-
    • Sodium, hypo-
    • Urea, hyper-
  • Mechanical
    • Airway obstruction
    • Cerebral herniation
    • Spinal cord compression
    • Superior vena cava obstruction
    • Other locations that obstruct outflow
  • Neurologic
    • Cerebrovascular accidents
    • Seizures
    • Syndrome of inappropriate antidiuretic hormone
  • Other
    • Medication side effects
    • Medication interactions
    • Organ failure
    • Tumor rupture
  • Other problems, not necessarily are emergencies but can be
    • Dehydration
    • Graft vs host disease
    • Immunosuppression
    • Iron overload
    • Mucositis
    • Pain

Questions for Further Discussion
1. What are the most common pediatric cancers? A review can be found here
2. How do pediatric cancers present?
3. Steroids are used for many problems. What is the problem with using steroids if there is an undiagnosed malignancy?
4. What are PDQs from the National Cancer Institute and how can they be helpful? 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: Cancer in Children and Cancer – Living with Cancer.

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.

Prusakowski MK, Cannone D. Pediatric Oncologic Emergencies. Hematol Oncol Clin North Am. 2017;31(6):959-980. doi:10.1016/j.hoc.2017.08.003

Stephanos K, Picard L. Pediatric Oncologic Emergencies. Emerg Med Clin North Am. 2018;36(3):527-535. doi:10.1016/j.emc.2018.04.007

Handa A, Nozaki T, Makidono A, et al. Pediatric oncologic emergencies: Clinical and imaging review for pediatricians. Pediatr Int Off J Jpn Pediatr Soc. 2019;61(2):122-139. doi:10.1111/ped.13755

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

What Causes Early Pregnancy Vaginal Bleeding?

Patient Presentation

A 16-year-old female called into clinic with a history of abdominal pain for 3-4 days. She described pain that was mainly in her lower abdomen and said she was also having some dark brown vaginal discharge that started that morning. The pain was increasing and she was having nausea but no emesis. She was sexually active and was using Depo-Provera® as her method of birth control. Her last shot was 20 weeks previously. She had been tested for sexually transmitted infections at that time too because she had a new partner. She was worried she was pregnant and wanted to know what she should do. She also denied being light headed or feeling like she was going to pass out. She denied any other vaginal discharge before today.

The diagnosis of vaginal bleeding in the setting of possible early pregnancy was made and the patient was referred to the emergency room. In the emergency room, an early intrauterine pregnancy diagnosis was made. She was managed with expectant monitoring and the bleeding resolved. She eventually delivered a healthy baby boy.

Discussion

Pregnancy complications in early pregnancy range from mild to severe. They can include nausea and emesis which often is treated symptomatically, but can cause hyperemesis gravidarum and need hospitalization for intravenous fluids. Mild cramping and slight spotting are not uncommon. Some type of pregnancy bleeding is common with 20-40% of women experiencing it. Women who have early vaginal bleeding have a higher risk of later pregnancy complications.

Pregnancy in adolescents is about 10% of all pregnancies. Adolescent pregnancy can be associated with various problems including higher rates of threatened abortion, pre-eclampsia, Cesarean section, pre-term delivery and lower birth weights. A review can be found here.

Patients with vaginal bleeding need to be evaluated for hemodynamic stability. Young women especially can lose a significant amount of blood before becoming hemodynamically unstable. Physical examination may reveal abdominal tenderness or signs of an acute abdomen such as rigidity, distension and guarding. Vaginal speculum examination helps to determine location of the bleeding. Bimanual examination can help to determine cervical motion or pelvic tenderness, and uterus size. Evaluation includes serum hCG (human chorionic gonadotropin) levels, ultrasound to try to determine if there is an ectopic or intra-uterine pregnancy and other labs such as hemoglobin/hematocrit and type and cross-match for potential transfusion. The patient’s blood type should be obtained if not known and Rh D immunoglobulin given for Rh negative women. Signs of acute abdomen, cervical motion or pelvic tenderness and tissue in the cervical os are usual reasons for surgical and/or gynecological consultation. Patient with threatened abortion are often managed expectantly with most women having complete expulsion of the products of conception within a few weeks. Management of ectopic pregnancy is medical management with medication such as methotrexate or surgical management particularly if the patient is hemodynamically unstable or has signs of a surgical abdomen.

Learning Point
Potential causes of bleeding in early pregnancy include:

  • Ectopic pregnancy – increased risk with mini-pill or intrauterine device, pelvic infection or sexually transmitted infection, previous ectopic pregnancy, use of assisted reproduction for the pregnancy
  • Threatened abortion
  • Endometrial implantation
  • Malignancy
  • Vaginal or cervical polyps
  • Uterine infection
  • Gestational trophoblastic disease
  • Hemorrhoids

Questions for Further Discussion

1. How do you evaluate heavy menstrual bleeding? A review can be found here

2. How do you evaluate and treat dysfunctional uterine bleeding? A review can be found here

3. What are protective factors to help prevent teenage pregnancy?

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: Vaginal Bleeding and Health Problems In Pregnancy.

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.

Breeze C. Early pregnancy bleeding. Aust Fam Physician. 2016;45(5):283-286.

Bleeding in Early Pregnancy. American Family Physician. https://www.ncbi.nlm.nih.gov/pubmed/30702267. Accessed April 13, 2020. 286.

Karatasli V, Kanmaz AG, Inan AH, Budak A, Beyan E. Maternal and neonatal outcomes of adolescent pregnancy. J Gynecol Obstet Hum Reprod. 2019;48(5):347-350. doi:10.1016/j.jogoh.2019.02.011286.

Pontius E, Vieth JT. Complications in Early Pregnancy. Emerg Med Clin North Am. 2019;37(2):219-237. doi:10.1016/j.emc.2019.01.004286.

Author

Donna M. D’Alessandro, MD

Professor of Pediatrics, University of Iowa

When Can You Use A Fingerprint to Identify Someone?

Patient Presentation

A newborn male was having his footprints taken in the newborn nursery. The intern asked, “I know that we do this, but is it ever used and how accurate is it?” “That’s a good question and I don’t know the answer. I know they use the footprint because it is a larger surface and therefore would have more points to measure. Plus it’s a lot easier to do than to get a hand or fingerprint from a baby. But that is about all I know,” the attending replied. The resident added, “With all the increase in biometric data being done these days, I wonder how early it can be used. Retinal scans for example. It would probably be easier to do that than to get the handprint from a baby.”

Discussion

Biometrics uses “biological characteristics or behavioral features to recognize an individual.”

Using biometric data requires acquisition of data of sufficient quantity and quality for recognition and comparison, and the biometric data needs to remain stable over time (i.e. – the person should be able to be recognized in the future using the data. Data acquisition and storage cost and size are also important variables. Privacy and security are also paramount considerations.

Biometrics use in pediatric patients has several applications including:

  • Newborn tracking -using biometrics for identifying a newborn and linking them to its mother to prevent newborn swapping in hospitals and maternity wards.
  • Health care – especially vaccination tracking. Many children in the world do not receive the necessary vaccines or they receive them at an inappropriate time or duplicate vaccines because an adequate documentation system is not available.
    There are non-governmental agencies using biometric data for vaccine registry and tracking.

  • Identifying missing children – biometrics could allow improved identification of missing children.
  • Government identification – biometric data to identify a person potentially over their lifespan for receiving appropriate governmental services.

The most common biometric techniques available include:

  • Fingerprint (or alternatively palm or footprints) (see below also)
    • One of the most used and preferred methods. Only 2% of the population cannot use fingerprints.
    • Can be harder to do in children because the space between the dermal ridges are small therefore even initial recognition can be difficult. As the child grows and the spacing increases, eventually the data may not be reliable in identifying the individual.
    • People who work with chemicals or wash their hands a lot can have problems with the scanning.
  • Finger vein
    • Similar to fingerprints but looks at the unique vein pattern
    • Pattern is stable in the adult population, has technical issues.
  • Facial recognition
    • Good because can be used for mass identification, doesn’t require cooperation and is contactless
  • Lip prints
    • Similar to facial recognition. The attributes of lips are unique and stable over time in adults.
    • Children’s faces change over time, lips are smaller and therefore have less data, has many technical issues.
  • Iris scanning
    • Very secure, contactless but have to hold still to get a good iris scan
    • The iris’s unique shape is stable by 10 months and is persistent throughout life. Iris scanning appears to be currently generally feasible from age 3-4 upwards.
  • Voice recognition
    • Easily used for many applications including speech-to-text for many computer applications today.
    • There are technical challenges with adult voices, and childrens’ voices change.

Learning Point

Fingerprints, and palm or footprints, are made by the distinct epidermal ridges of the skin and are also known as dermatoglyphs. They are formed in fetal life by 6 months gestation but the exact mechanism is not understood. It appears to be a combination of genetic and environmental effects such that even twins do not have the same fingerprints. The distinct patterns are persistent throughout life. Basic patterns include arches, loops, whorls or mixed but the patterns, number of ridges and locations make for an infinite amount of combinations and therefore no two patterns are the same.

Adermatoglyphia is the absence of dermatoglyphs and is caused by a SMARCAD1 gene mutation. There are no specific differences between males and females but men’s fingers are larger and therefore their fingerprints are larger.

People leave fingerprints on surfaces all the time. These are called latent prints and the latent print residue that is left behind contains oils, salts and sometimes DNA, but mainly latent prints contain water. Fingerprints could be altered because of damage or disfigurement, however that also makes the fingerprint more distinct and identifiable.

Questions for Further Discussion

1. If you needed to institute a biometric vaccine registry, what biometric data would you collect and what would some of the tradeoffs be?

2. What are some of the problems with voice recognition software in the adult population?

3. what are some of the privacy considerations for collecting and storing biometric data?

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: Genetic 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.

Fingerprints FAQ. http://www.madsci.org/FAQs/body/fingerprints.html. Accessed April 13, 2020.

OMIM Entry – #125590 – DERMATOGLYPHICS–FINGERPRINT PATTERN. https://www.omim.org/entry/125590. Accessed April 13, 2020.

UCSB Science Line. http://scienceline.ucsb.edu/getkey.php?key=2650. Accessed April 13, 2020.

Saini R, Rana N. Comparison of Various Biometric Methods. Int J Adv Sci Technol. 2014:2(1):24-30.

Jain AK, Arora SS, Best-Rowden L, Cao K, Sudhish PS, Bhatnagar A. Biometrics for Child Vaccination and Welfare: Persistence of Fingerprint Recognition for Infants and Toddlers. ArXiv150404651 Cs. April 2015. http://arxiv.org/abs/1504.04651. Accessed April 13, 2020.

Jenkinson H. Identified. JAMA Dermatol. 2017;153(10):982. doi:10.1001/jamadermatol.2017.2923

Masyn S, Vuchelen A, Santermans E, et al. Overcoming the challenges of iris scanning to identify minors (1-4 years) in the real-world setting. BMC Res Notes. 2019;12(1):448. doi:10.1186/s13104-019-4485-8

Are fingerprints determined by genetics? Genetics Home Reference. https://ghr.nlm.nih.gov/primer/traits/fingerprints. Accessed April 13, 2020.

Author

Donna M. D’Alessandro, MD

Professor of Pediatrics, University of Iowa

What Are Examples of Infantile Primitive Reflexes?

Patient Presentation
A 2-month-old female came to clinic for her health supervision visit. The parents were pleased with how well she was growing. “She’s amazing,” said her dad, “She can even walk,” and he proceeded to show the pediatrician how she would lift her feet and place them slightly forward when she was held upright. The past medical history showed a full term infant without prenatal or natal problems.

The pertinent physical exam revealed normal growth parameters in the 75-90%. She had a social smile. She had good tone and strength. Cranial nerves were intact and deep tendon reflexes were normal for age. She had a positive Babinski reflex. The pediatrician also pointed out other normal primitive reflexes including the Moro reflex, Asymmetric Tonic Neck reflex, Stepping and Placing reflexes as well as Galant and Perez. The diagnosis of of a healthy infant was made. “You’ll notice some of these reflexes for a while and then they will go away as her brain matures. Right now they show that she is doing well,” the pediatrician remarked. The parents smiled approvingly.

Discussion
As part of the normal developmental process of central nervous system maturation, primitive reflexes (i.e. infantile automatisms) occur which are automatic movement patterns which can begin during fetal development and continue after birth. Some appear important for human survival such as rooting and sucking to obtain nutrition. Others may be phylogenetic remnants. Primitive reflexes are present and disappear at predictable times and therefore can assist in evaluation of infant development. There is a range of normal and some can persist to older ages in some individuals. Primitive reflexes that occur before or after predicted times or that present asymmetrically on the body can potentially show abnormalities and therefore are important to note. Children and adults with various brain injuries or diseases also may show some of these primitive reflexes.

Learning Point
Examples of primitive reflexes include:

  • Rooting reflex
    • Mouth or cheek touched and infant turns head to that side
    • Present at birth
    • Disappears around 3-4 months, but can be seen in sleeping infants until 7-8 months
  • Sucking reflex
    • Sucking begins when nipple placed in infant’s mouth, or examiner’s finger is placed at the commissure of infant’s mouth
    • Present at birth
    • Disappears around 3-4 months, but can seen in sleeping infants until 7-8 months
  • Moro or Startle reflex
    • Infant is surprised/startled and the four limbs abduct and extend then abduct and flex. Infants will also extend the spine initially and then close the fingers. Startle is elicited by striking surface on either side of infant (original method by Moro), loud noise, or lifting the infant head and shoulders above body and allowing the head to drop (of course with support).
    • Present at birth, can be seen as early as 25 weeks gestation and is elicited by 30 weeks
    • Disappears around 3-4 months but normal up until 6 months
  • Stepping reflex
    • Infant held upright and slightly forward with feet on surface will raise legs and look like stepping or walking
    • Present at birth
    • Disappears around 2-3 months
  • Placing reflex
    • Infant held upright and dorsum of foot is touched by the edge of table. Infant lifts foot and places it on the table
    • Present at birth
    • Disappears by first year
  • Palmar grasp reflex
    • Examiner’s finger placed in infant palm at base of fingers and press applied. Infants finger’s flex to grasp the examiner’s finger. There are 2 phases – the catching of the examiner’s finger and the holding of the examiner’s finger
    • Present at birth, can be seen as early as 28 weeks gestation
    • Disappears by 6 months
  • Plantar grasp reflex
    • Examiner’s finger placed in infant sole at base of toes and press applied. Infants toes flex to curl around the examiner’s finger. There are 2 phases – the catching of the examiner’s finger and the holding of the examiner’s finger.
    • Present at birth
    • Disappears by 15 months
  • Babinski reflex
    • Pressure applied to sole of foot along the lateral edge starting with the heel and curving around to the base of big toe. Normal or negative is to have downward curving of the toes or no movement. A positive Babinski reflex, that of the toes curving upward, is normal in infants because of their immature neurological status.
    • Present at birth
    • Disappears by 1-2 years
  • Landau reflex
    • Infant is placed face down on a surface or in lateral suspension and the infant lifts its head and extends its legs
    • Present starting at 3 months
    • Disappears by 2 years
  • Blinking or Glabella reflex
    • Glabella is lightly tapped and both eyes blink. Habituation occurs with multiple attempts of the tapping
    • Present at birth
    • Disappears by 1 year
  • Asymmetric tonic neck reflex
    • With infant in supine position, head is gently rotated to one side. Extension of the lateral arm and flexion of the contralateral arm occur. This position is sometimes called the Fencer’s position.
    • Present around birth
    • Disappears by about 6 months
  • Symmetric tonic neck reflex
    • With infant in supine position, head is gently flexed. Extension of the head, arms and legs occurs
    • Present around 2 months
    • Disappears about 6-9 months
  • Parachute reflex
    • Infant prone in air and brought to the surface with the head down. Infant reacts as if trying to cushion a fall with their arms abducted and extended and fingers spread.
    • Present around 8-9 months
    • Present throughout life
  • Gallant reflex
    • Infant head prone in air and one side of lower spine lightly stroked. Infant’s spine contracts on that side causing the hips to move laterally on the side stroked (e.g. spine incurves).
    • Present at birth
    • Disappears around 2-4 months, up to 6 months
  • Perez reflex
    • Infant head prone in air and both sides of lower spine lightly stroked. Infant extends hips and legs.
    • Present at birth
    • Disappears around 2-4 months

Questions for Further Discussion
1. What do decerebrate and decorticate postures look like? What do they mean?
2. What informal or formal developmental evaluations do you carry out in the office?
3. What are indications for referral to a neurologist or developmental pediatrician?

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: Infant and Newborn Care 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.

Futagi Y, Toribe Y, Suzuki Y. The grasp reflex and moro reflex in infants: hierarchy of primitive reflex responses. Int J Pediatr. 2012:191562. doi:10.1155/2012/191562

Gieysztor EZ, Choinska AM, Paprocka-Borowicz M. Persistence of primitive reflexes and associated motor problems in healthy preschool children. Arch Med Sci AMS. 2018;14(1):167-173. doi:10.5114/aoms.2016.60503

Salandy S, Rai R, Gutierrez S, Ishak B, Tubbs RS. Neurological examination of the infant: A Comprehensive Review. Clin Anat N Y N. 2019;32(6):770-777. doi:10.1002/ca.23352

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