Pediatric Primary Care (120 page)

c.  Haloperidol (Haldol).

d.  Risperidone (Risperdal)–can cause weight gain.

e.  Pimozide (Orap)–monitor EKG for prolonged QT interval.

f.  Topiramate (Topamax)–limited studies, but can be effective.

I.  Follow up.

1.  To monitor progression of symptoms to see if they become disruptive.

2.  For education and assessment of comorbidities.

3.  Medication management.

J.  Complications.

1.  ADHD: seen in up to 70% of patients who have tics/Tourette syndrome.

2.  Obsessive compulsive disorder: seen in up to 50% of patients who have tics/Tourette syndrome.

3.  Depression.

4.  Anxiety.

5.  Muscle pain.

K.  Education.

1.  Explanation of tics and Tourette syndrome, no known specific cause and no harm to brain, most often “normal” child and IQ.

2.  Do not criticize child or draw attention to tics.

3.  Be sensitive to child's feelings, child unable to fully stop tics.

4.  Teach coping skills and relaxation techniques.

5.  Most children have tics for only a few months or less.

6.  One-third of children will outgrow Tourette syndrome.

7.  Discuss possible complications and when to treat.

BIBLIOGRAPHY

Arizona Sports Concussion Center. Heads up: Concussion in youth sports. Retrieved July 5, 2011, from:
www.azsportsconcussion.com/concussion.php
.

Bruun R, Cohen D, & Leckman J.
A physician's guide to the diagnosis and treatment of Tourette syndrome
. 3rd ed. Bayside, NY: Tourette Syndrome Association; 1997.

Center for Disease Control and Prevention. Concussion and TBI; 2010. Retrieved July 5, 2011, from:
www.cdc.gov/Concussion
.

Centers for Disease Control and Prevention. Traumatic brain injury; 2010. Retrieved July 5, 2011, from:
www.cdc.gov/TraumaticBrainInjury/index.html
.

Cleveland Clinic Staff. Migraines in children and adolescents; 2009. Retrieved July 5, 2011, from:
http://my.clevelandclinic.org/disorders/headaches/hic_migraines_in_children_and_adolescents.aspx
.

Devinsky O, Feldmann E, Weinreb H, & Wilterdink J.
The resident's neurology book.
New York: F. A. Davis; 1997.

Epilepsy Foundation. Types of seizures. Retrieved July 5, 2011, from:
http://www.epilepsyfoundation.org/about/types/types/index.cfm
.

Fusco E. Head injury causes, symptoms, diagnosis, and treatment; 2010. Retrieved July 5, 2011, from:
http://www.emedicinehealth.com/head_injury/article_em.htm
.

Goldenberg L. Beyond a single seizure, identification and treatment of epilepsy.
Advance for Nurse Practitioners.
2004;12(6):61-65.

Goldstein J. (2004). Evaluating new onset of seizures in children.
Pediatric Annals.
2004;33(6):368-374.

Heller J. Head injury.
Medline Plus;
2011. Retrieved July 5, 2011, from:
www.nlm.gov/medlineplus/ency/article/000028.htm
.

Hershey A, Kabbouche M. & Powers S. Treatment of pediatric and adolescent migraine.
Pediatric Annals
. 2010;39(7):416-423.

Huff J. Status epilepticus; 2010.
www.emedicine.medscape.com

Leung A, & Robson W. Febrile seizures.
Journal of Pediatric Health Care.
2006;21(4):250 -255.

Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, & Silberstein S. Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents: Report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society.
American Academy of Neurology.
2004;63:2215 -2224. Retrieved July 5, 2011, from:
www.neurology.org/cgi/content/full/63/12/2215
.

Mayo Clinic staff. Meningitis; 2008. Retrieved July 5, 2011, from:
www.mayoclinic.com/health/meningitis/ds00118
.

Mayo Clinic Staff. Encephalitis; 2009. Retrieved July 5, 2011, from:
www.mayoclinic.com/health/encephalitis/DS00226/DSECTION=symptoms
.

Mayo Clinic Staff. Headaches in children; 2009. Retrieved July 5, 2011, from:
www.mayoclinic.com/health/headaches-in-children/DS01132/DSECTION=symptoms
.

Pakalnis A, & Yonker M. ‘Other' headache syndromes in children.
Pediatric Annals.
2010;39(7):440-446.

Panayiotopoulos C. Idiopathic generalized epilepsies; 2008. Retrieved July 1, 2011, from:
http://professionals.epilepsy.com/page/ideopathic_generalized_epilepsies.html
.

Saper J, Silberstein S, Gordon C, & Hamel R.
Handbook of headache management: A practical guide to diagnosis and treatment of head, neck, and facial pain.
Philadelphia, PA: Lippincott Williams & Wilkins; 1993.

Shevell M, Ashwal S, Donley D, Flint J, Gingold M, Hirtz D, et al. Practice parameter: Evaluation of the child with global developmental delay: Report of the quality standards subcommittee of the Child Neurology Society.
Neurology.
2010;60:367-380.

Shinnar S, & O'Dell C. Febrile seizures.
Pediatric Annals.
2004;33(6):394-401.

Silberstein S, & Lipton R. Variants confused with epilepsy; 2004. Retrieved July 5, 2011, from:
www.professional.epilepsy.com/page/migraine_variants.html
.

Silberstein S, Lipton R, & Goadsby P. Headache in clinical practice. London, UK: Thomson; 2002.

Tourette Syndrome Association website:
www.tsa-usa.org

Vyas J. Encephalitis.
Medline Plus;
2008. Retrieved July 5, 2011, from:
www.nlm.nih.gov/medlineplus/ency/article/001415.htm
.

Wikipedia. Meningitis; 2010. Retrieved July 5, 2011, from:
www.en.wikipedia.org/wiki/Meningitis
.

Wyllie E, Gupta A, & Lachhwani D.
The treatment of epilepsy principles and practice
, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

CHAPTER 32

Hematologic Disorders

Betsy Atkinson Joyce

I.  IRON-DEFICIENCY ANEMIA (IDA)

A.  Most common anemia of childhood. Anemia is defined as reduction in red blood cell (RBC) mass or in hemoglobin concentration to a level that is > 2 standard deviations below mean in healthy children. Can be determined in primary care setting by physical examination, important aspects of history, and hemoglobin concentration. Screening should occur routinely around 9 months to 1 year. High-risk infants: screen earlier, more often.

B.  Etiology.

1.  Microcytic anemia reflecting defect in production of hemoglobin during erythrocyte maturation, resulting from defect in heme synthesis due to inadequate quantities of iron:

a.  Inadequate supply of iron at birth, inadequate dietary iron.

b.  High demand for iron associated with growth.

c.  Blood loss without replacement.

d.  Inflammatory bowel disease.

e.  Menstruation.

C.  Occurrence.

1.  Common between 1 and 3 years of age because of inadequate dietary iron due to cow's milk being major staple in most children's diets.

2.  Lack of adequate iron stores to meet needs for growth.

a.  Affects 9% of children younger than 2 years of age.

b.  Affects 9-11% of adolescent females.

3.  Lack of adequate iron to meet needs for RBC production.

a.  Affects 3% of children younger than 2 years of age.

b.  Affects up to 3% of adolescent females and < 1% of adolescent males.

D.  Clinical manifestations.

1.  Mild anemia (hemoglobin of 9.5-11): may be asymptomatic; sometimes only minimal symptoms when severe anemia (hemoglobin of 8-9.5 or lower) is present. May only be detected on routine screening or discovered when blood count ordered for another reason.

2.  History of fatigue, irritability, excessive milk intake, headaches.

E.  Physical findings.

1.  Mild anemia (normal physical exam).

2.  More severe anemia.

a.  Poor weight gain.

b.  Sclera or palmar pallor.

c.  Splenomegaly: 15% of affected children.

d.  Tachycardia.

e.  Systolic flow murmurs: with progression of the iron deficit.

F.  Diagnostic tests.

1.  Hemoglobin concentration
(
Table 32-1
).

2.  Complete blood count (CBC).