Melanonychia striata with multiple toenail involvement in a child

A 10-year-old Filipino boy with melanonychia striata affecting six toenails is described. The occurrence of melanonychia striata affecting so many toenails has not been reported previously in a Filipino child.

The limping child

A child who limps often presents a diagnostic challenge. The differential diagnosis is extensive. Although the most common cause is trauma, awareness of other potential causes is important. The age of the child and the pattern of the gait help narrow the differential diagnosis. In most cases, a diagnosis can be made from the history and physical examination. If the diagnosis is not obvious after a careful clinical evaluation, plain radiographs provide an excellent means of screening for fracture, joint effusion, lytic lesions, periosteal reaction, and avascular necrosis. Other tests should only be ordered when indicated.

Surgical outcome following treatment of isolated subaortic obstruction

Surgical and nonsurgical patients with isolated subaortic stenosis (SAS) were compared to determine the important factors contributing to the timing of surgical intervention. This study reviews 49 consecutive patients (27 surgical and 22 nonsurgical) aged 1.8 to 15.9 years with isolated SAS. The preoperative peak left ventricular outflow tract (LVOT) gradient in surgical patients was significantly higher than the gradient in nonsurgical patients (59.0 +/- 30.4 vs 22.77 +/- 13.9 mm Hg, P = .0001). The progression in LVOT gradient analyzed by echo Doppler was significantly higher in the surgical group compared with the nonsurgical group (10.48 +/- 9.7 vs 1.56 +/- 6.5 mm Hg/y, P = .007). Repeat surgical intervention was required in 22% of patients in the surgical group for recurrence of SAS, and 4% needed a third surgery. The progression in the severity of aortic regurgitation (AR) was not significantly different in the surgical and nonsurgical groups. There was a significant association between the development of AR and patients undergoing surgery (P = .045). AR may not be a reliable indication for early operative intervention in isolated SAS as there was no significant difference in its progression with surgical and nonsurgical patients. Asymptomatic patients with isolated SAS may warrant surgical intervention on the basis of progression of LVOT gradient, rather than the development or progression of AR.

Group A beta-hemolytic streptococcal pharyngitis in children

Group A beta-hemolytic streptococcus (GABHS) is the most common bacterial cause of acute pharyngitis in children. Because clinical findings can be nonspecific, even experienced physicians cannot reliably diagnose GABHS pharyngitis solely on the basis of clinical presentation. Suspected cases should be confirmed by a throat culture or a rapid antigen detection test before antibiotic therapy is initiated. Microbiologic testing is generally not necessary in patients with pharyngitis whose clinical and epidemiologic findings are not suggestive of GABHS. Clinical score systems have been developed to help physicians decide which patients should undergo diagnostic testing and to reduce the unnecessary use of antibiotics. Antibiotic therapy should be initiated as soon as the diagnosis is confirmed. Penicillin V remains the drug of choice. Alternative therapy, e.g., with cephalosporin or macrolide, is often sought because of penicillin allergy, noncompliance, and treatment failure.

Diagnosis and management of galactorrhea

After infancy, galactorrhea usually is medication-induced. The most common pathologic cause of galactorrhea is a pituitary tumor. Other causes include hypothalamic and pituitary stalk lesions, neurogenic stimulation, thyroid disorders, and chronic renal failure. Patients with the latter conditions may have irregular menses, infertility, and osteopenia or osteoporosis if they have associated hyperprolactinemia. Tests for pregnancy, serum prolactin level and serum thyroid-stimulating hormone level, and magnetic resonance imaging are important diagnostic tools that should be employed when clinically indicated. The underlying cause of galactorrhea should be treated when possible. The decision to treat patients with galactorrhea is based on the serum prolactin level, the severity of galactorrhea, and the patient's fertility desires. Dopamine agonists are the treatment of choice in most patients with hyperprolactinemic disorders. Bromocriptine is the preferred agent for treatment of hyperprolactin-induced anovulatory infertility. Although cabergoline is more effective and better tolerated than bromocriptine, it is more expensive, and treatment must be discontinued one month before conception is attempted. Surgical resection rarely is required for prolactinomas.

Internipple distance and internipple index

OBJECTIVE

To determine the internipple distance and internipple index in Chinese children.

METHODS

The internipple distance and chest circumference were measured in 3,290 healthy Chinese children (1,715 males and 1,575 females) aged birth to 18 years seen at the Asian Medical Centre. The internipple distance and chest circumference were obtained at the end of expiration whenever possible, with a standard nonstretch tape measure graduated in millimeters with the arms hanging relaxed alongside the body. Patients under two years of age were measured supine and those over two years of age standing. The internipple distance was measured between the centers of both nipples, and the chest circumference was measured across the internipple line. The internipple index was calculated according to the formula: internipple distance (cm) multiplied by 100 and divided by chest circumference (cm).

RESULTS

The internipple distance and chest circumference increased with age. The internipple index was highest in the neonatal period (26.4 +/- 1.6 for males and 26.3 +/- 2 for females), and decreased steadily until the age of four years (23.8 +/- 1.2 for males and 23.8 +/- 1.4 for females), and thereafter was relatively constant through the age of 18 years in males and the age of 11 years in females. In females, the internipple index decreased gradually from the age of 11 years to 18 years.

CONCLUSIONS

While internipple index is a more practical way to assess nipple placement, there are ethnic differences in the internipple index. Proper reference standards should be used in the assessment whether the nipples are closely or widely spaced.

A subungual nevus in a Filipino child

A 2.5-year-old Filipino girl with a progressively growing, black, subungual lesion is described. A biopsy was performed because of the progressive increase in size of the lesion and its periungual involvement. Histologic examination revealed a junctional nevus. To our knowledge, this represents the first report of subungual nevus in a Filipino child. The need for histologic diagnosis prior to definitive surgery cannot be overemphasized.

Mammary duct ectasia: a cause of bloody nipple discharge

We report a 13-year-old girl with bloody nipple discharge as a result of mammary duct ectasia. Our patient is the second reported case of mammary duct ectasia in a pubertal girl.

Acute sinusitis in children: diagnosis and management

Acute sinusitis is a common problem in children that is often overlooked. The pathophysiology is related to obstruction of the sinus ostia and mucociliary dysfunction. The predominant pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The diagnosis of acute sinusitis is based on persistent or severe upper respiratory tract symptoms. The routine use of roentgenograms to confirm the diagnosis of uncomplicated sinusitis is not recommended for children 6 years or younger but may be considered for children older than 6 years. Antimicrobial therapy is the cornerstone of management and amoxicillin is the drug of choice for most cases of uncomplicated sinusitis.

Current status of cryptorchidism

Cryptorchidism is present at birth in 3% to 5% of term male infants. The incidence is higher in preterm and low birth weight infants. The two most important possible sequelae are infertility and testicular tumor. Diagnostic studies are usually not necessary if the undescended testis is palpable. Laparoscopy has replaced imaging studies for localization of a nonpalpable testis and might also obviate the need for exploration of the groin. The recommended age for treatment has progressively decreased as our understanding of the problem has improved. Current information suggests that the placement of the testis in the scrotum should be accomplished by 1 year of age to maximize the potential for fertility. Treatment options include surgical relocation or hormonal therapy. The lower the pretreatment position of the testis, the better the success rate for either method.

Childhood cervical lymphadenopathy

Cervical lymphadenopathy is a common problem in children. The condition most commonly represents a transient response to a benign local or generalized infection, but occasionally it might herald the presence of a more serious disorder. Acute bilateral cervical lymphadenopathy usually is caused by a viral upper respiratory tract infection or streptococcal pharyngitis. Acute unilateral cervical lymphadenitis is caused by streptococcal or staphylococcal infection in 40% to 80% of cases. The most common causes of subacute or chronic lymphadenitis are cat scratch disease, mycobacterial infection, and toxoplasmosis. Supraclavicular or posterior cervical lymphadenopathy carries a much higher risk for malignancies than does anterior cervical lymphadenopathy. Generalized lymphadenopathy is often caused by a viral infection, and less frequently by malignancies, collagen vascular diseases, and medications. Laboratory tests are not necessary in the majority of children with cervical lymphadenopathy. Most cases of lymphadenopathy are self-limited and require no treatment. The treatment of acute bacterial cervical lymphadenitis without a known primary source should provide adequate coverage for both Staphylococcus aureus and group A beta hemolytic streptococci.

Familial clinodactyly of the fifth finger

We describe a caucasian family of which whom five members in three generations had clinodactyly of the fifth fingers. This report confirms that clinodactyly of the fifth finger can be transmitted as an autosomal dominant trait.

Attention deficit hyperactivity disorder: an update

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder, affecting 3% to 5% of school-aged children. Of the 3 subtypes--predominantly inattentive, predominantly hyperactive/impulsive, and a combined subtype--the latter is the most commonly represented group, accounting for 50% to 70% of all ADHD individuals. Stimulant medication is the cornerstone of management; however, stimulants with a short duration of action have been problematic for some patients. Recent technologic advances in delivery systems offer many patients the option of a once-daily dosage.

Duplication of the Testis with Contralateral Anorchism

We describe the case of a newborn infant with duplication of the testis and absence of the contralateral testis. The patient also had bilateral indirect inguinal hernias and an ipsilateral undescended testicle.

Acute abdominal pain in children

Acute abdominal pain in children presents a diagnostic dilemma. Although many cases of acute abdominal pain are benign, some require rapid diagnosis and treatment to minimize morbidity. Numerous disorders can cause abdominal pain. The most common medical cause is gastroenteritis, and the most common surgical cause is appendicitis. In most instances, abdominal pain can be diagnosed through the history and physical examination. Age is a key factor in evaluating the cause; the incidence and symptoms of different conditions vary greatly over the pediatric age spectrum. In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions. Diarrhea often is associated with gastroenteritis or food poisoning. Appendicitis should be suspected in any child with pain in the right lower quadrant. Signs that suggest an acute surgical abdomen include involuntary guarding or rigidity, marked abdominal distention, marked abdominal tenderness, and rebound abdominal tenderness. If the diagnosis is not clear after the initial evaluation, repeated physical examination by the same physician often is useful. Selected imaging studies also might be helpful. Surgical consultation is necessary if a surgical cause is suspected or the cause is not obvious after a thorough evaluation.

Managing childhood atopic dermatitis

Atopic dermatitis, a chronic inflammatory skin disorder that affects up to 20% of school-aged children, can profoundly influence quality of life. Basic therapy consists of avoidance of triggering factors and optimal skin care. Until now, corticosteroids have been the usual treatment for acute flares. Short-term safety profiles are reasonable, but long-term use of corticosteroids may involve significant adverse effects. Topical immunomodulators (tacrolimus and pimecrolimus) are beneficial and safe for adults and children and represent a major new alternative to chronic corticosteroid use, especially in children.

Benign neonatal hemangiomatosis

An infant with benign neonatal hemangiomatosis is described. Examination for internal hemangiomas was negative. The patient had complete resolution of the lesions by 2 years of age.

Congenital cytomegalovirus infection

Cytomegalovirus (CMV) is the most common congenital infection in humans. Congenital CMV infection can follow either a primary or recurrent maternal infection, but the likelihood of fetal infection and the risk of associated damage is higher after a primary infection. Approximately 90% of congenitally infected infants are asymptomatic at birth. Jaundice, petechiae, and hepatosplenomegaly are the most frequently noted clinical triad in symptomatic infants. More frequent and more severe sequelae occur in symptomatic infants, notably psychomotor hearing loss and retardation. Congenital CMV infection can be diagnosed by isolation of the virus from the urine or saliva within the first three weeks of life. Rapid diagnosis can be accomplished by detection of CMV DNA by DNA amplification or hybridization techniques.

Cholelithiasis in an infant with Klinefelter's syndrome

Cholelithiasis has been reported only rarely in infants. We describe a case of cholelithiasis in a 1-month-old infant with Klinefelter's syndrome. This association has not been previously reported.

Urotherapy recommendations for bedwetting

OBJECTIVE

To assess the efficacy of urotherapy recommendations prior to pharmacological or moisture alarm treatment in the management of bedwetting in children.

METHODS

Children assessed for bedwetting at a voiding dysfunction clinic were admitted to a prospective, uncontrolled pilot study. The families were instructed to follow specific urotherapy recommendations.

RESULTS

Of the 23 children who completed the study, sixteen (70%) improved with at least one less wet night per week, nine (39%) with at least a 50% reduction, and five (22%) resolved.

CONCLUSION

Urotherapy recommendations prior to pharmacological or moisture alarm treatment shows promise and potential for the management of children with bedwetting. Further studies are necessary to determine if the improvement is sustained.

Hemihypertrophy

Hemihypertrophy refers to asymmetry of the body to a greater degree than can be attributed to normal variation. Most causes can be diagnosed from history and physical examination. Hemihypertrophy is cosmetically unsightly and the psychological impact can be quite prolonged. This article reviews the causes and differential diagnosis of hemihypertrophy and offers an approach to the management of this condition. Children with isolated hemihypertrophy are at increased risk for neoplasms. Periodic abdominal ultrasound examination and physical examination during infancy and childhood are recommended for early tumour detection.