Recent Advances in Pediatric Medicine

This chapter discusses the difference between acute otitis media, recurrent otitis media, and otitis media with effusion as well as the etiology, epidemiology, diagnosis and treatment of the distinct diseases. New 2016 guideline updates on Otitis Media with Effusion from the American Academy of Otolaryngology are incorporated.

Hearing loss has a significant impact on children’s ability to develop adequate language and communication skills and often interferes with educational performance as well as limits long-term employment opportunities. Hearing loss is categorized into three broad categories: Conductive, Sensorineural, and Mixed. Audiology workup aims to identify the category and the level of hearing loss; evaluation is divided into subjective and objective tests. Rehabilitation is available to almost all kinds and degrees of hearing loss if diagnosed and managed in a timely manner. For that, we need to increase the awareness of the families and health care providers as well about the screening programs and advocate its implementation in all maternity and child care centers. In this chapter, we discuss acquired and congenital causes of hearing loss. We will also address the diagnostic workup, and finally will discuss in detail the recent developments in pediatric hearing rehabilitation.

An understanding of the anatomy and physiology of Waldeyer’s tonsillar ring is important to learning as how to diagnose and treat diseases in the upper aerodigestive tract. The physician should have an understanding of the many disease processes that can affect this region and how to treat them. The clinician should be aware of the possible complications of diseases in Waldeyer’s ring and the common presentations so these can be recognized and immediate treatment can be initiated. The physician should be knowledgeable of the current indications for tonsillectomy and adenoidectomy and be aware of the potential complications during the postoperative course.

Pediatric Chronic Rhinosinusitis (PCRS) is a common condition in otolaryngological practice. PCRS remains ill-defined as a condition as it remains difficult to establish as a diagnosis. PCRS may co-exist with other widespread conditions such as allergic rhinosinusitis and adenoiditis. Recent efforts have been targeted at defining this condition and to develop stepwise treatment. A consensus of statement was recently put out defining PCRS as at least 90 continuous days of nasal symptoms with corresponding endoscopic and/or image findings in a patient who is 18 years old or younger. With a working definition, research has focused on developing stepwise treatments ranging from medical management to endoscopic sinus surgery. This chapter focuses on discussing the developed treatments for PCRS.

Stridor is one of the most common reasons for referral to a pediatric ENT subspecialist. This chapter is prepared as technical update for the advanced practitioner (neonatologist, pediatrician, family physician, general ENT) as a supplement to existing classic textbook material. In addition to existing established surgical approaches, newer and more conservative treatment techniques are increasingly successful as the primary or adjunct treatment. Surgical and medical practice continues to be shaped by increased awareness of and demand for conservative procedures and higher risk aversion. Management of stridor now requires a greater variety of updated medical and surgical expertise. Increased collaboration between specialists allows for an extended period of interventions and introduces new challenges and perspectives for all involved. - Practical skills for interview, assessment of the severity and cause of stridor are discussed in detail from the perspective of the pediatric ENT subspecialist collaborating closely with several other subspecialty areas.

Laryngomalacia (LM) is the most common cause of stridor in children. It presents during the first days of life with inspiratory stridor often associated with feeding difficulties. Diagnosis must be confirmed by performing a flexible fiberoptic laryngoscopy. LM is classified in mild, moderate and severe LM depending on respiratory and feeding severity symptoms. LM usually goes with gastroesophageal reflux disease, and can also be associated to synchronous airway lesions, neurological disorders, heart disease and congenital syndromes. Identification and management of co-morbidities using appropriate complementary examinations are essential as they influence LM severity and treatment outcomes. Medical management of LM includes lifestyle/dietary measures and anti-acid treatment. Supraglottoplasty, including several technique variants, is the mainstay of severe LM treatment, with numerous studies reporting high success and low complications rates. Tracheotomy and non-invasive ventilation are indicated in case of supraglottoplasty failure, most of the time due to associated neurological disorder and congenital syndromes.

Diabetes involves pancreatic dysfunction due to autoimmune destruction of the beta cells and insulin deficiency. The prevalence and incidence of Type 1 and Type 2 are increasing in the general population. Type 1 Diabetes often begins in childhood and requires lifelong insulin replacement therapy and monitoring of blood glucose levels. Long and short-acting insulin allows for adjustment of therapies around patients’ lives, but close medical observation and a good patient-provider relationship is necessary for optimal management. Type 2 Diabetes is characterized by severe insulin resistance and partial deficiency that has become more prevalent in pediatric patients, often occurring around puberty. Therapy involves lifestyle changes to promote active weight loss, healthy eating habits, and exercise. Few pharmacological therapies are approved, but many are being studied for pediatric use.

Pediatric Type 2 Diabetes Mellitus (T2DM) is an increasing medical concern for the pediatric community. It is most commonly diagnosed in adolescents but has also been seen in patients as young as 5 years of age. Presentation of T2DM can range from mild symptoms of polyuria, polydipsia and nocturia to diabetic ketoacidosis. Guidelines by the American Diabetes Association are used to diagnose and treat children with diabetes. Early diagnosis and aggressive treatment is critical in delaying complications of diabetes. Poorly controlled diabetes can lead to significant increase in morbidity and mortality with development of hypertension, nephropathy and retinopathy. In this chapter, a review of the epidemiology of Type 2 diabetes, diagnosis and treatment options will be discussed.

The worldwide prevalence of pediatric obesity has increased remarkably over the past three decades turning pediatric obesity into a serious and challenging public health concern. One in three children and adolescents in the US are overweight or obese. Pediatric obesity is associated with numerous comorbidities, cardiovascular risk factors, and adulthood obesity. Obesity has been a major contributor to increasing healthcare expenses. Increasing awareness of pediatric obesity in the public as well as the healthcare platform is essential to tackle the problem and plan primary and secondary prevention. Given the limited pharmacotherapy options for pediatric obesity, a multifaceted approach of lifestyle changes involving nutrition, physical activity and behavior modification is needed. In order to make a meaningful impact, collaboration among the government, employers, schools, healthcare and other organizations from the community is required. This chapter intends to provide a comprehensive yet concise review of evaluation and management of pediatric obesity.

Graves’ disease (GD) is the most common cause of hyperthyroidism in children and adolescents. It is an autoimmune disorder, caused by immunologic stimulation of the thyroid stimulating hormone receptor (TSHR). Thyrotropin stimulating immunoglobulin (TSI) binds to TSHR and leads to thyroid hormone overproduction. Clinical features include fatigue, tremors, palpitations, heat intolerance and poor school performance. The diagnosis is by findings of increased heart rate and goiter in the setting of suppressed thyrotropin stimulating hormone and elevated free thyroxine. Radioactive iodine uptake and serum antibody measurements help to determine the cause of hyperthyroidism. Treatment options for GD include antithyroid drugs, radioactive iodine or surgery. Lasting remission occurs in 15 to 30% of children with GD. Thus, a majority of children will require definitive therapy with radioactive iodine or thyroidectomy. A discussion of advantages and risks of each therapeutic option is essential to help the patient and family select a treatment option.

In the past decade, there have been great advances in the approach to and management of pediatric asthma. Recent progress includes improved definitions, established guidelines, and novel therapeutic modalities. There is growing recognition that asthma is a heterogeneous entity and as such, individualized therapy is now standard when creating intervention plans. Asthma severity is classically categorized based on the concepts of impairment and risk. As more specific data is gathered on asthma subgroups, molecular pathways and cluster analysis, there has been a movement for categorizing patients into asthma phenotypes, which could serve to tailor therapies and optimize clinical response. This chapter will review the pathophysiologic processes involved in asthma; expose the latest definitions of asthma and management guidelines; discuss the implications of the “phenotypic” approach in pediatric asthma and present an overview of pertinent recent therapeutic advances.

Bronchiolitis is the most common cause of hospitalization in infants and children less than 2 years of age. Patients typically present with signs of an upper respiratory tract infection that then progress to symptoms consistent with a lower respiratory tract infection. The key to diagnosis is the history and physical examination; labs and chest radiography are not routinely necessary or recommended. Treatment is largely supportive as many of the therapies that are effective in other respiratory diseases are ineffective in the treatment of bronchiolitis. Emphasis should therefore be on prevention and reducing transmission of the disease. Areas of focus for the prevention of bronchiolitis include administration of palivizumab prophylaxis in selected infants and children, hand hygiene, elimination of tobacco smoke exposure, encouragement of breastfeeding, and family education.

Central Sleep Apnea (CSA) in children is a far less studied and understood abnormality compared to Obstructive Sleep Apnea (OSA). It is seen more often in younger patient population mostly with co-morbidity. There are structural abnormalities in the brain, spinal cord, airway and chest wall or functional disorders in respiratory control, hemoglobin concentration, swallowing or cardiovascular system, resulting in CSA. Clinical observation of central apneic events prompts further evaluation ideally done by performing Polysomnography testing (sleep study) to confirm the presence and estimate the severity. Various medical and surgical treatment options result in improvement or resolution of the central apneic events. Majority of the patients show a gradual resolution of the disorder with age. However a minority of patients continue to manifest the disorder and require longer term treatment mostly by using respiratory support in the form of invasive or non-invasive ventilation. More research is needed to explore treatment options for children.

Obstructive sleep apnea syndrome (OSAS), affecting about 5% of all children, has positioned itself to be a major epidemiological problem in the United States. The prevalence of this condition appears to be increasing over time, in parallel with the growth in childhood obesity. Pediatric OSAS belongs to a spectrum of respiratory disorders called sleep-disordered breathing (SDB), caused by varying degrees of paroxysmal upper airway obstruction during sleep. Left untreated, OSAS has potential to progress over time, leading to not just fragmented sleep, but also neurocognitive problems, and in the most severe instances, serious cardiopulmonary adverse effects. The treatment of OSAS involves a structured series of steps spanning medical and surgical approaches, including adenotonsillectomy, which is considered the gold standard for management of childhood OSAS. This chapter provides a review of the epidemiology of OSAS, followed by a discussion of natural history, treatment and follow up.

Involuntary passage of gastric contents into the esophagus may be physiologic (Gastroesophageal Reflux-GER) or may be associated with troublesome symptoms (Gastroesophageal Reflux disease-GERD). GER is common in infants and is related to immature anti reflux mechanisms. On the other hand, GERD needs further evaluation. Presenting features of both include esophageal symptoms like vomiting and extra esophageal symptoms such as irritability, reflux laryngitis, pharyngitis and dental erosions. Upper GI series is not recommended for diagnosing GERD. Traditional pH probe examinations have been replaced largely by combined multi-channel Impedance –pH monitoring which helps establish a temporal relationship between symptoms and pathological reflux, as well as ascertain the acidic versus non acidic, solid versus liquid or gas nature of the refluxate. Proton pump inhibitors remain the mainstay of treatment, along with H2 receptor antagonists and prokinetic agents. Surgical intervention should be reserved for selected severe cases.

Sickle cell disease (SCD) is the most common inherited disorder identified by newborn screening programs with an estimated 100,000 individuals living with SCD in the United States (US). The most severe phenotype of SCD is seen in patients with homozygous hemoglobin SS (HbSS) also known as sickle cell anemia. Common morbidities include invasive pneumococcal infection due to loss of splenic function, pulmonary sickling causing acute chest syndrome, cerebrovascular stroke, acute pain episodes and the development of chronic pain syndromes. Life expectancy for SCD has improved and children born with SCD today have a greater than 90% chance of survival to adulthood. Disease modifying therapies including the use of simple and chronic transfusions and oral hydroxyurea to both treat and prevent disease complications such as pain, stroke and acute chest syndrome. The only curative option for SCD remains hematopoietic stem cell transplantation with the best outcomes from a matched sibling donor.

Objective: To describe the etiology, diagnostic examination, and management options of recurrent epistaxis in children, to help clinicians better delineate which patients might benefit from conservative versus more aggressive therapies. Results: Epistaxis occurs frequently in children, and affected children are often seen by primary care, emergency department, and otolaryngology physicians. Knowledge of the underlying etiology, diagnostic examination techniques, and available treatment options is essential for clinicians. A review of the current literature was performed, and this chapter provides information about epistaxis management. Most cases of epistaxis are self-limited and respond well to conservative treatments, such as lubricants and antiseptic ointments; however, some cases will require hematologic testing, diagnostic imaging, and intraoperative assessment and management. Conclusions: Epistaxis is a common diagnosis in children. Clinicians should be familiar with the etiology and management of this condition in children.

Allergic rhinitis (AR), the most common chronic disease in children, is the fifth most common chronic disease in the United States. Otolaryngologists see a large percentage of patient’s whose disease process is often associated with, or caused by, upper and lower airway inflammation. Because allergy is a common contributor to airway inflammation, a working knowledge of the treatment options for pediatric allergic rhinitis is essential in the evaluation and management of children presenting to otolaryngologists.

Anaphylaxis is a dangerous condition that must be treated quickly. The prevalence is on the rise, and the diagnosis requires a low index of suspicion in someone experiencing the typical constellation of symptoms involving more than one body system after exposure to a possible allergen. Treatment involves the administration of intramuscular epinephrine before consideration of any other modalities. While treatment of anaphylaxis with epinephrine always comes first, specific laboratory tests including serum tryptase and directed specific IgE tests can be considered to help aid in the diagnosis. Finally, every patient who experiences anaphylaxis should be discharged with injectable epinephrine and an emergency action plan.

It is important for pediatricians to increase their expertise in the area of Autism Spectrum Disorders (ASD). With the increase prevalence rate of ASD and the emphasis on early detection, pediatricians need to be familiar with diagnostic criteria for ASD and know when to refer for a comprehensive evaluation. After a formal diagnosis is given, pediatricians will be “front line” in the medical management of comorbid medical/psychiatric symptoms of ASD for their patients. They will serve as the medical home for families to guide evidence-based treatment options and to help find community resources for the child with ASD. The goals of this chapter are to provide an overview of ASD diagnostic criteria; to increase knowledge in early detection and diagnosing ASD; provide information about common medical comorbidities for individuals with ASD; and build knowledge in guiding families as they find evidencedbased therapeutic resources for their child with ASD.

Pediatric providers can play a key role in the early identification and treatment of anxiety. Brief screening tools can be used to enhance detection and differentiation of anxiety symptoms. Once identified, providers can triage concerns to determine the best course of action, including treatment setting (primary care versus referral to an outpatient provider) and intervention approach (cognitive-behavioral therapy, medication management). Distraction and parent education can be effective tools to reduce short-term anxiety associated with office-based procedures. More longterm treatment of anxiety, either within primary care or in community-based settings, can vary depending on presenting concerns and the child’s age. However, evidencebased approaches typically include psychoeducation, cognitive behavioral therapy, recognition and management of physical cues of anxiety, cognitive restructuring, exposures, relapse prevention, and collaboration with parents and schools. Medication may be a useful way to augment treatment in certain circumstances.