Chest pain in children.

In a retrospective study of chest pain, 267 children were identified. This gave an occurrence rate (per patient visit) of 0.249%. Male patients were identified as often as female patients, and teenagers as often as children less than age 12 years. Chest pain was found to be present for more than 1 month in 8.6% and for more than 1 year in 7.8%. Idiopathic chest pain was the most common diagnosis made, followed by functional pain (anxiety related) and musculoskeletal pain. Laboratory tests were not helpful in establishing the etiology of chest pain.

Blood lead levels in children with foreign bodies.

To determine the risk of increased blood lead levels in children with aural, nasal, or gastrointestinal foreign bodies, the authors prospectively obtained venous blood lead and erythrocyte protoporphyrin levels from 40 study patients and two control groups without foreign bodies (65 patients presenting to a medical clinic and 40 patients presenting to an emergency department). A questionnaire was used to assess environmental and behavioral risk factors for lead poisoning in the three groups. Mean blood lead level was higher in children with foreign bodies (P less than .001), and they were more likely to have a venous blood lead value of more than 1.2 mumol/L (25 micrograms/dL, P less than .01) than patients in either control group. Seventy-eight percent of study patients had no prior lead screening by parent's report vs 64% of emergency department control subjects and 55% of medical clinic control subjects. Control patients in the emergency department had the same incidence of elevated blood lead values as patients enrolled from the medical clinic (6%). No differences in environmental risk factors were found among the three groups. Study patients more often had a history of pica or ingestion of a poison than control patients from the medical clinic. Inner-city children with foreign bodies have increased lead exposure and may have an increased risk for lead poisoning. In areas of high prevalence of lead poisoning, children with foreign bodies should be screened for lead poisoning in the emergency department. General lead screening in the emergency department may be justified for high-risk, inner-city populations.

Pediatric chest pain: a prospective study.

Previous studies of childhood chest pain have been retrospective or considered only limited age groups or referred patients. In this study, all children who were admitted to the emergency department with chest pain were evaluated prospectively. Patients with ill-defined chest pain had ECGs and echocardiograms performed. A total of 407 children were evaluated. The most common causes of the pain were idiopathic (21%) and musculoskeletal (15%). Cardiac problems were found in 4%. Chest pain was acute (of less than 48 hours' duration) in 43% and chronic (of greater than 6 months' duration) in 7%. Pain caused 30% of children to stay out of school and 31% to awaken from sleep. Chest wall tenderness was the most common abnormality. ECGs were obtained in 47%; results of 31/191 were abnormal but only 4/191 ECG abnormalities were related to the diagnosis. Echocardiograms were obtained in 34%; results of 17/139 were abnormal (12/139 showed mitral valve prolapse). Young children are more likely to have cardiorespiratory problems; children older than 12 years of age are more likely to have psychogenic pain. The description and location of the pain and the patient's sex are not related to the diagnosis. Nonorganic disease is related to a family history of heart disease or chest pain or having chronic pain. Organic disease is related to pain of acute onset, abnormal physical examination results, pain that awakens the child from sleep, and the presence of fever. Laboratory tests are rarely helpful in evaluating children with chest pain. Chest pain in children is usually benign. Psychogenic pain and idiopathic pain are less common than previously believed.

Thermal epiglottitis after swallowing hot beverages.

Two young children who sustained thermal injuries to the epiglottis (or "thermal epiglottitis") after swallowing hot beverages are reported. Findings, clinically and radiologically, in both children were similar to acute infectious epiglottitis. Children with these injuries are at risk for significant upper airway obstruction which may progress for several hours. Children in whom thermal epiglottitis is suspected should be approached with the same caution and preparedness for emergency airway management and pediatric intensive care afforded those with acute infectious epiglottitis.

Lead poisoning in a child with a gunshot wound.

Lead poisoning has infrequently resulted from gunshot wounds with retained lead particles in adults. This has not been previously found in children. The case of an 8-year-old boy in whom lead poisoning developed soon after a gunshot wound is reported. The child had no symptoms directly related to lead poisoning, but he received chelation therapy. The case demonstrates the need to consider lead poisoning in children with retained particles following gunshot wounds.

The effect of blood lead on blood pressure in children.

The effect of elevated blood lead levels on the blood pressure of children has not been clearly described. In order to define this association better, we conducted a cross-sectional study, evaluating the association between lead and high blood pressure. Using a Dinamap monitor to measure blood pressures, blood pressures and blood lead levels were measured in 149 children (ages 1-10 years) receiving medical care at the General Medical and Lead Poisoning Clinics at Children's Hospital of Philadelphia. Blood lead levels ranged from 7 to 70 mg/dL with a mean of 27 mg/dL. The mean systolic blood pressure was 108 mmHg and the mean diastolic reading was 63 mmHg. Higher systolic blood pressure was significantly correlated with increased weight, age, and height. Diastolic pressure was significantly associated with weight and height. There was a small, negative correlation between blood lead levels and systolic blood pressure, and a positive but insignificant correlation between lead levels and diastolic blood pressure. Our study population had both higher mean lead levels and a higher prevalence of hypertension than is true of the U.S. population as a whole. We concluded that elevated blood lead levels are not associated with elevated blood pressure in children.

The treatment of pain in the emergency department.

Our approach to the management of fear and pain in the pediatric emergency department is presented. Tricks to attempt the gaining of rapport with frightened children in pain are noted, with emphasis on a developmental approach. The use of analgesic medications, local anesthetics, ketamine, and nitrous oxide as appropriate to emergency situations is outlined. Lastly, the guidelines of the American Academy of Pediatrics for outpatient sedation are reviewed.

Vulvar hemangioma simulating child abuse.

An infant with a vulvar hemangioma that had undergone extensive ulcerative changes was initially diagnosed as having a perineal burn secondary to child abuse. Although genital burns are a well-recognized manifestation of child abuse, knowledge of the natural course of untreated hemangiomas and the uncommon complication of ulceration as well as familiarity with the characteristic patterns of abusive burn injuries may allow the physician to avoid making this misdiagnosis. The confusion in diagnosis led to an extensive social service investigation that, in this case, had a positive outcome for the mother's ability to cope. There exists, however, the possibility of iatrogenic-induced emotional stress if child abuse is misdiagnosed.

Chest pain in children. Follow-up of patients previously reported.

During a 1-year period, 407 children with chest pain were seen in the Emergency Department of Children's Hospital of Philadelphia. Analysis of the clinical data of these children was reported previously. The authors successfully followed 149 of these children for 6 months or more, and 51 for 2 years or more. These patients returned for an average of 3.4 visits during the follow-up period. Thirty-four percent of the initial diagnoses were altered. Usually, during the follow-up period, the authors concluded that chest pain resulted from nonorganic causes. A new organic etiology was uncovered in only 12 of 149 cases. Only 1 child was found to have a heart abnormality (mitral valve prolapse), and 3 were found to have asthma. Chest pain did not resolve during the follow-up period in 43 percent of those followed. Children with chest pain should have follow-up care because of the persistence of symptoms, but serious disease is unlikely to be found over time.

Lead encephalopathy. A case report and review of management.

Acute lead encephalopathy has become a rare syndrome in the United States. Early recognition of the disease, with institution of specific chelation therapy, is critical in order to minimize mortality and morbidity. Lead intoxication, however, may mimic other more common diseases. We report an 8-year-old child with known sickle cell anemia who presented initially with findings suggestive of vaso-occlusive crisis but who deteriorated rapidly and was found to have severe lead poisoning. We present her hospital course and review the management of lead encephalopathy in detail.

Back pain in children who present to the emergency department.

The purpose of this study was to identify the causes and epidemiology of back pain in children who present to the emergency department. All children who presented to an urban pediatric emergency department (ED) during a 1-year period with the chief complaint of back pain were examined and evaluated with a uniform questionnaire. This was completed at the time of the ED visit in 48%, and within 48 hours in 52%. During a 1-year period, 225 children with a complaint of back pain were evaluated. The mean age was 11.9 +/- 4 years and 60% were female. Onset was acute (< or = 2 days) in 59%, and chronic (> or = 4 weeks) in only 11.6%. Pain awakened children from sleep in 47%, and caused 52% to miss school or work. The most common diagnoses were direct trauma (25%), muscle strain (24%), sickle cell crises (13%), idiopathic (13%), urinary tract infection (5%), and viral syndrome (4%). Radiographs of the back were rarely helpful. About 5% required hospital admission; one half of these were attributed to sickle cell crises. We conclude that back pain is an uncommon reason for children to present to an emergency department. When present, pediatric back pain is most often musculoskeletal, associated with an acute infectious illness or a traumatic event. Although the etiology is rarely serious, back pain often affects the daily activities of symptomatic children.

Teaching technical skills in pediatrics.

Technical skills are an important and difficult part of managing a very sick or injured child. However, technical procedures are more often learned from experience than practice. This article reviews a variety of technical skills and procedures commonly performed in a pediatric emergency department. Each technical procedure can be practiced using live or artificial model for simulation.

Epiglottitis: a review of 13 cases and a suggested protocol for management.

Thirteen cases of epiglottitis are reviewed in this paper. Fever and respiratory distress were the most common presenting symptoms. A lateral neck roentgenogram was a helpful laboratory test. Epiglottitis must be distinguished from viral croup and other causes of upper airway obstruction so that prompt treatment can be instituted. A suggested protocol for management of epiglottitis emphasizes the importance of establishing an artificial airway and administering intravenous antibiotics effective against Hemophilus influenzae type B.