H
Hand, Foot, and Mouth Disease
http://www.cdc.gov/hand-foot-mouth/index.html
Head LICE
http://www.cdc.gov/parasites/lice/
Headache Related to Eye Problems
What is a headache?
What causes a headache related to the eye?
Who gets a headache?
How does it cause disease?
What are the common findings?
How is a headache diagnosed?
How is a headache treated?
What are the complications?
How is a headache prevented?
Robert A. King, M.D. The Children’s Hospital Denver, Colorado
What is a headache?
Commonly described, a headache is pain in the head. Generally, a headache is not dangerous; however, it can be a symptom of an underlying ocular problem or a serious neurological problem.
What causes a headache related to the eye?
The following conditions related to the eye may cause a headache:
Convergence insufficiency: Difficulty converging both eyes simultaneously to focus on reading.
Accommodative insufficiency: Difficulty focusing one eye at a time on reading, thereby requiring reading glasses.
Migraine: Periodic attacks of a vascular headache.
Strabismus: Any misalignment of the eyes.
Refractive errors: Any need for glasses, for example, nearsighted (myopic), farsighted (hyperopic), or astigmatism.
Increased intracranial pressure: Increased pressure around the brain caused by a neurological condition.
Special conditions (for example, albinism or nystagmus): Most commonly, these conditions lead to focusing problems.
Typically, when a child complains of a headache to a pediatrician that may be attributed to eye fatigue and/or eyestrain, the child is referred to a pediatric ophthalmologist, a doctor who specializes in eye care and surgery for children. With the pediatrician, the pediatric ophthalmologist helps to diagnose and treat the child.
Who gets a headache?
Children often complain of headaches. Most commonly, these children are aged from 2 years to 19 years, with an average age of 10 years. Migraine headaches occur in 2.7% of children by age 7 and in 10.9% of children by age 14; onset in children by age 4 is not uncommon. Headaches caused by convergence or accommodative insufficiency usually do not occur until school age and often not until third or fourth grade when the reading print becomes smaller and it takes a longer time to finish assignments.
How does it cause disease?
A headache is a symptom of a problem, not a disease in its own right. The conditions listed above can be ocular causes of headaches. Headache itself does not cause medical damage, but one of the above listed conditions may cause it.
What are the common findings?
Convergence Insufficiency
Convergence insufficiency usually occurs in the school-aged child who complains of a chronic headache, typically for several months. The child may have difficulty with learning to read; in particular, the child may hold reading material close to the face in an attempt to overcome the blurry vision. This process usually overtaxes already weak convergence amplitudes, which are a measure of a person’s ability to focus both eyes simultaneously on a reading target. The problem may occur several times a week, if not daily, and may occur in school or with homework, with relief on weekends or vacations. The child does not complain of headaches that awaken the child from sleep or of headaches that occur upon awakening in the morning. Nausea and vomiting do not occur with this condition. The child may complain of double vision or may be seen closing or covering one eye, presumably to avoid double vision.
Accommodative Insufficiency
The signs and symptoms of this condition are exactly the same as convergence insufficiency. The child may complain of blurry vision or may simply complain of headache with or after reading. Sometimes, accommodative spasm may be the diagnosis. In this situation, the child becomes focused excessively at near, actually locking the eyes in this focused position. Blurry vision occurs when the eyes are raised to look in the distance.
Migraine
Migraine is a common form of headache in children. Because of the frequently associated visual disturbances, children with migraine often are referred to a pediatric ophthalmologist. Migraine is classified as classic migraine, or migraine with aura; common migraine, or migraine without aura; and complicated migraine.
Migraine with Aura
Migraine with aura begins with the appearance of focal neurologic symptoms, such as numbness in a limb or facial paralysis on one side. Typically, visual symptoms last from 4 to 60 minutes (not seconds or days). Classically described, these symptoms are jagged lines of light surrounding a central blind spot that expand to the peripheral visual field. A child may describe visual symptoms as colorful, bright, flickering, turning, and moving. Some children may describe a kaleidoscope-like effect. Younger children who may not be able to describe these findings should be encouraged to draw it.
Migraine auras generally are followed by an intense, pounding headache located on one side of the head that lasts from two to four hours. The child typically will seek rest, without encouragement, in a quiet, dark room.
Migraine Without Aura
This condition is not associated with preceding visual symptoms. Instead, poorly defined symptoms, generally characterized by behavioral or gastrointestinal disturbances, precede the headache attack by hours to days. The headache begins on one side of the head but often spreads to the whole head, typically lasting hours to several days. Nausea and vomiting, phohobia (avoiding light), and phonophobia (avoiding noise or even sound) are more frequent in this type of migraine than in migraine with aura.
Complicated Migraine
This condition is associated with other neurologic phenomenon, including the ophthalmoplegic migraine, where the patient is unable to move an eye from side to side. Such a condition can occur in children, and it is characterized by periodic episodes of ophthalmoplegia, beginning at the peak of the headache and involving all functions of the oculomotor nerve. The headache usually occurs on the same side and is located around the orbit of the eye. The weakness may last for several weeks after the resolution of the headache.
An unusual form of complicated migraine is the Alice in Wonderland syndrome. Alterations in time and body image, as well as visual distortions, such as shrinking, enlargement, inversion, and elongation, characterize this syndrome.
Strabismus
Strabismus is defined as misalignment of the eyes. With this condition, the eyes can cross (esotropia), turn out (exotropia), or undergo vertical deviation (hypertropia). Any strabismus may cause headaches, with the same signs and symptoms as convergence insufficiency; however, strabismus diagnosed by the ophthalmologist differentiates the two conditions. Frequently, the parents may notice that the child covers or squints one eye with either reading or distance activity or both. Presumably, this action occurs because the child is attempting to avoid having double vision. A history of head trauma or other specific inciting event may result in nerve palsy of one of the nerves (i.e., cranial nerves III, IV, and VI) that move the eye muscles.
Refractive Errors
Refractive errors are the optical condition of the eyes that cause blurry vision, which clears by wearing glasses. Astigmatism and farsightedness are the two refractive errors that may cause a child to experience focusing problems, leading to fatigue and then headache. Astigmatism is when the front surface of the eye is shaped less like a sphere and more like an egg when one meridian is distorted. Farsightedness (hyperopia) is the optical condition when the eye is too short for the focusing system, thereby forcing the patient to excessively focus the lens of the eye (accommodate) to bring images to focus on the retina of the eye. The child often complains of headaches on school days or after long periods of reading when focusing effort has been at a maximum; no headaches occur when the child is not reading. A child with significant astigmatic error may hold reading material too close to the face simply because the words look blurry. This action, in turn, demands that the child accommodate more and converge more to be able to read. If the child holds reading material too close for too long, even normal accommodative and convergence amplitudes are inadequate to sustain long periods of reading.
Increased Intracranial Pressure
A child experiencing a headache that is caused by a brain tumor is quite significant. Classic findings include headaches that awaken the child at night, nausea and vomiting with the headache, and frequently accelerating symptoms over a relatively short time. Recurring morning headaches may be significant; however, this finding also may be related to sinus disease. Additionally, the child may complain of double vision (diplopia), jiggling vision (oscillopsia), or blurry vision. Pseudotumor cerebri is elevated pressure in the head that is not associated with an anatomic cause, such as a brain tumor or hydrocephalus. It occurs in children with prior head trauma, in children who are taking Accutane for acne, or in children who are taking prednisone, for example as part of a chemotherapy regimen. In some teenagers, this condition may occur without any reason.
Special Conditions
A child may complain of headaches that result from an unusual diagnosis, such as albinism or nystagmus. Albinism is a specific ocular disorder caused by decreased body pigment in the skin and in the eye, where vision is decreased because the retina has a deficiency of cells. Nystagmus, which is best characterized as ” jiggling eyes,” results because the vision is poor or because of a primary motor instability that is congenital in nature. Nystagmus also can be caused by other entities.
The history is especially important in assessing whether the headaches occur with reading or other near effort. A child with albinism complaining of headaches may experience eyestrain by holding reading material close to the face, because of the poor vision. A child with nystagmus of any cause may hold reading material close to the face because it dampens the nystagmus (reduces the jiggling) and enlarges the print.
How is a headache diagnosed?
To determine the cause of a headache relating to each of the above listed conditions, a history of the circumstances surrounding the headache and associated symptoms, a physical examination for neurological abnormalities, and an ocular examination should all be performed. The history is very important from both the parents and the child. The time course of the headache should be recorded. The frequency and the circumstances in which the headache occurs also may be important; for example, a headache may occur in school after the child reads for 15 minutes.
Associated symptoms should be explored. The pediatric ophthalmologist should be informed of other physicians who have examined the child; other tests that have been performed; other medical problems of the child; and other signs or symptoms observed by the parents, such as abnormal head positions, closing one eye, vomiting, redness, or swelling.
The eye examination is important. The pediatric ophthalmologist will check the child’s visual acuity (how the child reads the eye chart) at distance and near, with one eye at a time (monocular) and with both eyes simultaneously (binocular). The child’s eye alignment will be recorded in all positions of gaze (looking in every direction) and with left and right head tilt. Accommodative and convergence amplitudes will be measured, and the refractive error will be determined frequently after using dilating drops. The pediatric ophthalmologist will perform a slit lamp examination and a funduscopic examination, with close observation of the optic nerve, examining it for evidence of increased intracranial pressure.
Further diagnostic testing generally is not necessary. However, in the case of complicated migraine, glucose tolerance testing to rule out diabetes or neuroimaging (a CT scan or MRI scan of the head) to rule out serious intracranial pathology may be required. With other conditions (for example, strabismus or increased intracranial pressure), neurological testing, including neuroimaging, may be required.
How is a headache treated?
Convergence Insufficiency
To treat this condition, the pediatric ophthalmologist may prescribe a trial of patching with reading. The patch overcomes any strain induced by attempting to use the eyes together. If reading improves or if the headaches decline in frequency, magnitude, or duration with an eye patch, then the eyestrain induced by the effort to focus is being relieved.
Treatment for this condition is aimed at avoiding the problem or increasing reduced convergence amplitudes. If the child holds reading material too close to the face, then the reduced convergence amplitudes will cause eye fatigue/headaches in a shorter time frame. Therefore, holding reading material further from the face often is helpful. Exercises can be done to improve reduced convergence amplitudes. Convergence amplitudes are measured using a prism bar. When the amplitudes fall well below the normal range, exercises should be done. The exercises normalize reduced amplitudes. Relieving convergence insufficiency is the single most useful application of eye exercises.
Parents can begin this exercise with the aid of an orthoptist, who can train and instruct both the parents and the child. The parents should record feedback from this exercise. Two sessions of exercises, each lasting six to eight weeks, usually is recommended. The exercise can be performed at home, 15 minutes per day, with the supervision of an orthoptist once a month. The child should not have to enroll for a year of vision therapy. The end point of treatment for this condition is normalization of convergence amplitudes and/or relief of symptoms.
Accommodative Insufficiency
Measuring accommodative amplitudes is part of the eye examination. The near point of accommodation can be excessively recessed. Reading glasses are used to move the near point of accommodation close to the face. To treat this condition, it is recommended that the parents buy an inexpensive pair of over-the-counter reading glasses for the child to wear when reading. The headaches may resolve by either the placebo effect of the glasses or true accommodative insufficiency. In either case, the parent may choose to have a formal pair of bifocal glasses prescribed by the pediatric ophthalmologist.
Migraine
The best treatment for migraine includes reassurance, avoidance of precipitating factors, abortive therapy, and prophylactic treatment. Abortive therapy includes rest with or without the use of acetaminophen, anti-inflammatory drugs, or antiemetics. Prophylactic treatment, including beta-blockers, calcium channel blockers, or antidepressants, may be indicated for frequent, incapacitating headaches.
Strabismus
Treatment is directed at alleviating strabismus with glasses (with or without a bifocal), prism glasses, occlusion (patching the eye), or surgery. When the patient has accommodative esotropia, a hyperopic glasses prescription will alleviate the crossing of the eyes and the headaches. Prism glasses are used occasionally to optically align the eyes for small amounts of strabismus. Surgery to realign the eyes is ultimately required in numerous strabismus conditions. The mechanical realignment by moving the muscles that move the eyes is often the only treatment to relieve double vision.
Refractive Errors
For a child who is farsighted (hyperopic) or nearsighted (myopic) or who has astigmatism, glasses are required. More complicated combinations of hyperopic, myopic, astigmatic, or anisometropic refractive error require formal glasses prescriptions from a pediatric ophthalmologist. Bifocal glasses rarely are needed outside of accommodative insufficiency or high accommodative convergence/accommodation ratio.
Increased Intracranial Pressure
For the conditions related to increased intracranial pressure, such as brain tumors or hydrocephalus, neurosurgical intervention is the ultimate treatment. Follow-up care with a pediatric ophthalmologist is recommended to ensure that the optic nerve returns to its normal appearance. Additionally, computerized visual field examinations are beneficial and should be performed on a periodic basis. Any ongoing loss of visual field indicates that the intracranial pressure is not being controlled; in this case, intracranial pressure monitoring is indicated.
Special Conditions
For the child with special conditions, such as albinism and nystagmus, strong reading glasses may relieve this relative accommodative insufficieny.
What are the complications?
In the case of increased intracranial pressure, the child may continue to complain of headaches even after the appropriate treatments have been performed. Failure to control the pressure can lead to ongoing optic nerve damage. Ultimately, the child can become blind if the intracranial pressure is not controlled or if the optic nerve is not protected.
How is a headache prevented?
Routine eye examinations with a pediatric ophthalmologist are recommended to ensure that any significant eye abnormalities are diagnosed and treated appropriately.
To prevent migraine headaches, such precipitating factors as stress, chocolate, nitrates, certain cheeses, and monosodium glutamate (flavor enhancer) should be avoided. Additionally, in girls, oral contraceptives may worsen migraine headaches.
References
Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features. Am J Dis Child. 1982 Feb;136(2):121-4.
Hupp SL, Kline LB, Corbett JJ. Visual disturbances of migraine. Surv Ophthalmol 1989 Jan-Feb;33(4):221-36.
King RA. Common ocular signs and symptoms in childhood. Pediatr Clin North Am 1993 Aug;40(4):753-66.
Mapstone T. Brain tumors in children. In: Tomsak RT, ed. Pediatric Neuro-ophthalmology. Newton: Butterworth-Heinemann Medical; 1995:79.
McManaway JW. Management of common pediatric neuro-ophthalmology problems. In: Wright KW, ed. Pediatric Ophthalmology and Strabismus. St. Louis: Mosby-Year Book; l995:63.
Moore A. Hydrocephalus. In: Taylor D, ed. Pediatric Ophthalmology. London: Blackwell Scientific; 1990:499.
Nelhaus G, Stumpf DA, Moe PG. Neurologic and muscular disorders. In: Kempe CH, Silver HK, O’Brien D, eds. Current Pediatric Diagnosis and Treatment. Los Altos: Lange Medical Publishers; 1984:653.
Troost BT. Migraine and other headache. In: Duane TD, Jaeger EA, eds. Clinical Ophthalmology. Philadelphia: Harper and Row; 1997.
About the Author
Dr. King graduated from the United States Air Force Academy in 1972, with a Bachelor of Science degree. After spending 5 years in the Air Force, he went to medical school at the University of Colorado, graduating in 1981. He completed ophthalmology residency training at the University of Colorado in 1985, followed by a pediatric ophthalmology fellowship at Wills Eye Hospital in Philadelphia in 1986. Since then he has been in private practice in Denver, specializing in pediatric ophthalmology and adult strabismus.
He has been involved in resident training at The Children’s Hospital of Denver, and with other resident training programs as well. Past positions include co-director of pediatric ophthalmology at the Children’s Hospital in Denver, President of the Colorado Ophthalmological Society (now the Colorado Society of Eye Physicians and Surgeons), medical board member, and co-medical director of Anchor Center for Blind Children. He has been a regular contributor at the National Symposium for Nurse Practitioners, most recently chairing a symposium on the pediatric fundoscopic exam in July 2001. He has authored numerous articles in the field of pediatric ophthalmology.
Dr. King is married. He and his wife Carla have 2 children, Eric age 17 and Brian age 10.
Copyright 2012 Robert A. King, M.D., All Rights Reserved
Hemangioma
What is a hemangioma?
What causes hemangiomas?
Who gets hemangiomas?
How do hemangiomas cause disease?
What are the common findings of hemangiomas?
How are hemangiomas diagnosed?
What are the complications of hemangiomas?
How are hemangiomas treated?
How are hemangiomas prevented?
What research is being performed?
Are there links to other information?
by Joseph Morelli, M.D.
Associate Professor of Dermatology and Pediatrics
University of Colorado School of Medicine
What is a hemangioma?
A hemangioma is a benign tumor of the blood vessels (“capillary endothelium”). Some hemangiomas occur as birthmarks, often spontaneously improving.
What causes hemangiomas?
The cause of hemangiomas is unknown.
Who gets hemangiomas?
Hemangiomas are a very common benign tumor of infancy. Hemangiomas occur in up to 10% of the population, most commonly in females and in premature infants.
How do hemangiomas cause disease?
Because they are tumors, hemangiomas have a mass effect, meaning they take up space or room, which is caused by the growth of the tumor.
What are the common findings of hemangiomas?
Only 20% of hemangiomas are present at birth. The other 80% occur during the first two months of life, usually within the first month. They appear as white-gray blue flat spots, swollen “spider veins” (telangiectasias), or raised bumps. Then, they undergo a rapid growth phase, lasting from six to nine months, in which they grow faster than the child’s rate of growth. After this time, the growth of the hemangioma slows and approximates the growth rate of the child. The stable growth phase lasts until 12 to 18 months of age at which time the hemangioma begins to undergo “involution.” During the involution phase, the tumor shrinks on its own, without the need for treatment. Maximum shrinkage occurs in 50% of children by age 5, in 70% of children by age 7, and in 90% of children by age 9.
Parents should know that hemangiomas do not always completely disappear; in some cases, the affected skin does not return to its normal appearance.
Some hemangiomas leave recognizable marks following shrinkage of the tumor. These include decreased skin color; spider veins; excess lax skin; fibrous fatty deposits; and scarring, if the skin has broken down over the hemangioma.
Hemangiomas can appear as three different forms. The first type is the superficial bright red form, formerly known as the strawberry mark. The second type is the deep blue nodule, formerly known as a cavernous hemangioma. The third type is a combination of the superficial and the deep forms, which is called a mixed hemangioma. Commonly, the terms “superficial,” “deep,” and “mixed” are used to describe the three different types of hemangiomas.
How are hemangiomas diagnosed?
Hemangiomas usually are diagnosed based on an examination and the history of the lesion. Occasionally, magnetic resonance imaging is performed to determine the depth of involvement of the tumor; however, this procedure is rarely necessary or helpful.
What are the complications of hemangiomas?
Most hemangiomas are uncomplicated and do not require treatment. Complications of hemangiomas include ulceration (a breakdown of the overlying skin), infection, interference with a vital function, and, even, high output cardiac failure. Initially, the Kasabach-Merritt syndrome, which is a bleeding disorder, was thought to occur with hemangiomas; however, now, it is thought to occur with hemangioendotheliomas, which are a much less common and more aggressive tumor. Ulceration is the most common complication of hemangiomas. Ulcerated hemangiomas occur most commonly on the lip and in the diaper areas. If a lesion is ulcerated, it is at risk for infection. Staphylococcus aureus is the most common bacteria in infected hemangiomas. Vision, breathing, eating, urination, and bowel movements may all be obstructed by large, rapidly growing hemangiomas.
How are hemangiomas treated?
Most hemangiomas do not require treatment. Ulcerated hemangiomas are best treated with a specific type of laser. This leads to rapid healing of the open area. Infection is treated with specific antibiotics for Staphylococcus aureus. Large, rapidly growing hemangiomas, or hemangiomas that interfere with a vital function, are treated with systemic therapy. (Systemic therapy is treatment that affects the whole body, as opposed to localized treatment, and can be given either by mouth or intravenous injection.) Prednisone is the initial treatment of choice. It usually is given for two weeks. If after two weeks of therapy the tumor growth has been slowed, treatment is then tapered over the next four weeks. If there is no initial effect of therapy, the dose of prednisone is maintained for another two weeks. The patient should be seen every two weeks during therapy. Occasionally, after therapy is sped, there will be some rebound growth of the tumor. If this growth is substantial, therapy should be restarted. Interferon-alfa also has been used to treat hemangiomas. The use of interferon-alfa should be reserved for hemangiomas that do not respond to prednisone therapy.
How are hemangiomas prevented?
Currently, hemangiomas cannot be prevented.
What research is being performed?
The research most applicable to hemangiomas is being performed in the area of inhibiting the formation of new blood vessels (anti-angiogenesis). Since hemangiomas are vascular tumors, any therapy that inhibits blood vessel formations should impede hemangioma growth. At this time, agents that inhibit blood vessel formation have not yet been used for hemangioma therapy.
Are there links to other information?
A support group for families with children with hemangiomas is available at: The National Organization of Vascular Anomalies, P.O. Box 0358, Findlay, OH 45839-0358, phone number: (419) 425-1593, e-mail: hemangnews@msn.com and on the web at www.novanews.org.
References
Rasmussen JE. Vascular birthmarks in children. Dermatology Nursing 10:169-177, 1998.
Frieden IJ. Which hemangiomas to treat-and how? Arch Dermatol 133:1593-1595, 1997.
Morelli JG. Hemangiomas and vascular malformations. Pediatric Annals 25:91-96, 1996.
About the Author
Joseph received his undergraduate degree from the University of Pennsylvania, graduating Summa cum Laude with honors in biophysics. He completed his medical school training in 1981 from the Harvard University School of Medicine.
He is board certified in pediatrics and dermatology and completed his residencies in the same specialties. Joseph is a Pediatric Dermatologist with major interest in birthmarks and vascular lesions.
He spends most of his free time coaching Little League Baseball and Midget Football!
Copyright 2012 Joseph Morelli, M.D., All Rights Reserved
Hepatitis A
What is hepatitis?
What is hepatits A?
Who gets hepatitis A?
How does it cause disease?
What are the common findings?
How is hepatitis A diagnosed?
How is hepatitis A treated?
What are the complications?
How can hepatitis A be prevented?
What research is being done?
Links to other information
Michael R. Narkewicz, M.D.
Hewit-Andrews Chair in Pediatric Liver Disease
Associate Professor of Pediatrics, Medical Director,
The Pediatric Liver Center
University of Colorado School of Medicine and The Children’s Hospital
Denver, Colorado
What is hepatitis?
The term “hepatitis” is used to describe inflammation, swelling, or soreness of the liver. Hepatitis can have many different causes, including the hepatitis A, B, and C viruses; the delta and hepatitis E viruses; the Epstein-Barr virus (the mono virus); the cytomegalovirus (CMV); the herpes simplex virus; and varicella (chicken pox).
Other causes of hepatitis include toxins, such as drugs or alcohol. More rarely, autoimmune diseases, bacterial infections, fungal infections, and parasitic infections can cause hepatitis. The three most common causes of hepatitis are the hepatitis A, B, and C viruses.
What is hepatits A?
The hepatitis A virus (an RNA virus) causes hepatitis A. This virus infects the liver and causes liver injury. Hepatitis A is the most common cause of acute viral hepatitis in the world.
Who gets hepatitis A?
Hepatitis A commonly is spread from person-to-person by contact with a stool from an infected person, or from water or food that has been contaminated by infected stool. Hepatitis A also can be found in shellfish from certain waters where raw sewage may drain. It often can pass from caregivers to children or adults in settings where there is close contact.
Most commonly, adults are exposed in small epidemics due to contaminated food or water sources. However, in 40% of people, no known risk factor can be identified. In the United States, approximately 10% to 20% of children have been exposed to hepatitis A by five years of age. Most of these children do not have symptoms when infected. In developing countries, the hepatitis A infection is very common in children (near 100%).
How does it cause disease?
Hepatitis A generally is ingested in contaminated food or water. It is absorbed by the body, and then is taken into the liver cells. Following an incubation period of 15 to 50 days (average of 30 days), the liver cells are injured during the process of the body trying to eliminate the virus.
What are the common findings?
The incubation period for hepatitis A is about four weeks (i.e., after being exposed to the virus, a patient will not have any symptoms for about four weeks). Then, the patient usually will have flu-like symptoms, including malaise, vomiting, diarrhea, and fatigue. Jaundice (yellow eyes) often develops as the flu-like symptoms lessen; however, many times, particularly in children, jaundice will not be apparent. Liver blood tests, particularly AST and ALT, are abnormal.
After a period of illness, from one to four weeks, the jaundice will clear, the liver blood tests will normalize, and almost all patients will recover. Rarely, patients can have a relapse of jaundice for over six months. Very rarely, hepatitis A can lead to liver failure (less than 1 out of 10,000 cases).
How is hepatitis A diagnosed?
Hepatitis A can be diagnosed by a blood test, which looks for an antibody (anti-hepatitis A IgM) that is produced to the virus. If a patient has abnormal liver blood tests (e.g., bilirubin, AST, or ALT), a physician will suspect hepatitis A.
How is hepatitis A treated?
No medications have been shown to be effective in treating hepatitis A. In fact, most individuals recover from it without any specific treatment. In patients who are deeply jaundiced, a low-fat diet may reduce diarrhea. A Vitamin K supplement may help reduce the risk of bleeding in patients who are jaundiced for a long period of time. In the rare case of liver failure, a liver transplant may be the only treatment option.
What are the complications?
The most feared complication is liver failure; however, it very rarely occurs. Other complications, while rare, include pancreatitis, rashes, myocarditis, and relapsing hepatitis for up to six months. Cholestatic hepatitis, with itching as a major symptom, is another rare complication of hepatitis A. It may be treated with corticosteroids.
How can hepatitis A be prevented?
The primary prevention against hepatitis A is good handwashing and sanitation practices. Post-exposure prophylaxis with immunoglobulin has been the standard method of preventing hepatitis after an individual has been exposed to hepatitis A. Immunoglobulin may not be effective if given more than two weeks after an exposure. However, since hepatitis A can be prevented by vaccination with the hepatitis A vaccine, the use of immunoglobulin is declining. Several inactivated hepatitis A vaccines are available. The hepatitis A vaccination is recommended for those individuals (older than two years)
who will be traveling to countries where hepatitis A is very prevalent;
who have a high exposure risk, such as daycare workers;
who have chronic liver disease;
who have been exposed to hepatitis A during a community epidemic; or
who have clotting factor disorders, and are likely to be treated with factor concentrates.
Other high-risk groups include certain Native American populations where hepatitis A may be very prevalent, laboratory workers handling the virus, sewage workers, health care workers, and individuals who work with primates.
Recent research has suggested that the hepatitis A vaccination early in the course of a hepatitis A epidemic may prevent the development of hepatitis A among individuals who are exposed to the virus. After exposure to the virus, gamma globulin can prevent the development of hepatitis A.
What research is being done?
Current research efforts have resulted in the licensing of two vaccines. Additional work is concentrated on developing a live, attenuated vaccine that would be useful in third-world countries. Ongoing research also is focused on the use of these vaccines as prophylaxis in epidemics and the development of combination vaccines.
Links to other information
For more information on hepatitis A, log on to the following Web sites:
Center for Disease Control-Viral Hepatitis A
National Digestive Diseases Information Clearing House
References
Innis BL, Snitbhan R, Kunasol, et al. Protection against hepatitis A by an inactivated vaccine. JAMA 1994;271:1328-34.
Katkov WN. Hepatitis vaccines. Med Clin North Am 1996;80:1189-1200.
Keefe EB, Iwarson S, McMahon BJ, et al. Safety and immunogenicity of hepatitis A vaccine in patients with chronic liver disease. Hepatology 1998;27:881-6.
Lemon SM, Thomas DL. Vaccines to prevent viral hepatitis. N Engl J Med 1997;336:196-204.
Koff RS. Hepatitis A. Lancet 1998;341:1643-9.
About the Author
Dr. Narkewicz graduated from the University of Vermont School of Medicine and completed his training in Pediatrics and Pediatric Gastroenterology at the University of Colorado. He holds the Hewit-Andrews Chair in Pediatric Liver Disease and is Associate Professor of Pediatrics at the University of Colorado and the Medical Director of the Pediatric Liver Center and Liver Transplantation at The Children’s Hospital, Denver, Colorado.
Copyright 2012 Michael R. Narkewicz, M.D., All Rights Reserved
Hepatitis A vaccine
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-a.html
Hepatitis B
What is hepatitis?
What is hepatitis B?
What causes hepatitis B?
Who gets hepatitis B?
How does it cause disease?
What are the common findings?
How is hepatitis B diagnosed?
How is hepatitis B treated?
What are the complications?
How can hepatitis B be prevented?
What research is being done?
Links to other information
by Michael Narkewicz, M.D. Hewit-Andrews Chair in Pediatric Liver Disease Associate Professor of Pediatrics, Medical Director, The Pediatric Liver Center Section of Pediatric GI, Hepatology, and Nutrition University of Colorado School of Medicine, The Children’s Hospital Denver, Colorado
What is hepatitis?
The term “hepatitis” is used to describe inflammation, swelling, or soreness of the liver. Hepatitis can have many different causes, including the hepatitis A, B, and C viruses; the delta and hepatitis E viruses; the Epstein-Barr virus (the mono virus); the cytomegalovirus (CMV); the herpes simplex virus; and varicella (chicken pox). Other causes of hepatitis include toxins, such as drugs or alcohol.
More rarely, autoimmune diseases, bacterial infections, fungal infections, and parasitic infections can cause hepatitis. The three most common causes of hepatitis are the hepatitis A, B, and C viruses.
What is hepatitis B?
Hepatitis B is a liver disease. The hepatitis B virus (HBV) causes hepatitis B. This virus is a DNA virus that typically is transmitted by exposure to contaminated blood or other body fluids.
What causes hepatitis B?
HBV, the virus that causes hepatitis B, is the most common form of acute and chronic viral hepatitis throughout the world. In 1965, HBV was the first virus discovered to cause hepatitis.
Who gets hepatitis B?
In the United States, there are approximately 150,000 new cases of hepatitis B per year, and an estimated 1 to 1.25 million people have chronic infection with HBV. Hepatitis B primarily is transmitted by exposure to contaminated blood or body fluids. In the United States, HBV is spread by intimate contact with individuals who have HBV (e.g., sexual activity or needle sharing among intravenous drug users). The virus can be transmitted from mothers to their babies at the time of delivery.
In developing countries, this is quite common. In the United States, it still may occur, but usually can be prevented if the caregivers are aware of the mother’s HBV status. The virus also may be transmitted through small exposures to blood (e.g., minute cuts, abrasions, sharing of toothbrushes, or contaminated piercing equipment or tattooing equipment). Individuals with a high rate of exposure to infected patients, such as health care workers, also are at risk.
How does it cause disease?
HBV acutely infects the liver. There is an incubation period of 28 to 160 days, with an average of 80 days before symptoms may develop. Most adults develop acute hepatitis due to HBV. The body then develops immunity to the virus, and it is eliminated. Approximately 5% to 10% of adults who develop acute HBV infection go on to develop a chronic infection with HBV (i.e., lasting longer than 6 months).
In children, particularly newborns and children less than 1 year of age, about 75% to 90% will develop a chronic HBV infection. Individuals with chronic HBV infection can develop progressive scarring of their liver due to inflammation and are at increased risk for liver cancer.
What are the common findings?
Many patients (about 50%) with acute hepatitis B infection do not have any symptoms. Those patients who develop acute symptomatic hepatitis have flu-like symptoms, such as fever, malaise, muscle aches, vomiting, diarrhea, and anorexia. Some patients will develop jaundice (yellow eyes), pale stools, and dark urine. These symptoms generally clear over four to six weeks. In most adults, immunity to the virus is developed, and it is eliminated. From 5% to 10% of adults develop chronic HBV infection.
During this phase, they may be without symptoms, or they may have ongoing symptoms that are similar to acute hepatitis; however, the symptoms generally are milder. In children, particularly newborn infants, an acute hepatitis infection usually is without symptoms. Thus, the acute HBV infection generally is silent, and develops into a silent chronic infection in most children under one year of age.
During the acute phase, liver blood tests often are abnormal, particularly AST, ALT, and, less commonly, bilirubin. During a chronic infection, liver blood tests can be normal or abnormal.
How is hepatitis B diagnosed?
HBV is diagnosed by blood tests. These blood tests include:
(a)HBsAg: Hepatitis B surface antigen. This test measures a protein from the virus and indicates that a person is infected with the virus. Persistence of HBsAg for more than six months indicates chronic infection.
(b) Anti-HBs: Antibody to hepatitis B surface antigen. This antibody develops when HBV is cleared from the body, or after the hepatitis B vaccine.
(c) Anti-HBc-IgM. This IgM antibody to the HBV core antigen is present only with an acute infection. IgG develops in any patient who has been infected or is chronically infected.
(d) HBeAg: Hepatitis B e antigen. This measures a protein from the virus, indicating that the virus is replicating (i.e., making a new virus) at a high rate. This often is present early in the course of chronic HBV infection.
(e) Anti-HBe: Antibody to hepatitis B e antigen. This develops when a chronically infected individual begins to build up an immune response to the virus and becomes a chronic carrier of the virus.
How is hepatitis B treated?
There is no treatment for acute HBV, except for supportive care. Liver failure can develop with HBV, and a liver transplant may be required.
Although chronic HBV is difficult to treat, treatments are available. Most patients with chronic HBV have normal liver blood tests and do not require treatment. In general, individuals who receive treatment for chronic HBV show signs of ongoing liver injury by liver blood tests and/or a liver biopsy. The current treatments available include immunomodulatory therapies, such as interferon. This shot is administered 3 times a week for 24 weeks.
Approximately 25% to 30% of children with chronic hepatitis due to HBV will respond to therapy with interferon. Nucleoside analogs, such as Lamivudine, are approved for the treatment of adults, and are currently under study for use in children. A liver transplant may be required for chronic HBV that has progressed to end-stage liver disease.
What are the complications?
Acute HBV can be complicated by a serum sickness like illness, arthritis, or a rash. Other complications associated with acute hepatitis B infection include kidney disease (membranous nephropathy), a rash (e.g., papular acrodermatitis, Gianotti syndrome), and aplastic anemia. Rarely, acute HBV can lead to liver failure, requiring a liver transplant, or even causing death.
Chronic HBV infection is associated with various complications, including liver fibrosis or cirrhosis and liver failure. In patients who have chronic HBV infection, there is an increased risk of developing liver cancer. Kidney disease (membranous nephropathy) also may occur.
How can hepatitis B be prevented?
Avoiding high-risk behaviors can prevent hepatitis B. However, individuals without identified risk factors can acquire HBV.
The hepatitis B vaccine is very effective at protecting fully vaccinated individuals from contracting hepatitis B. It is a series of three shots that is part of the universal vaccination of children in the United States.
The Hepatitis B Immune Globulin (HBIG or NABI�-HB) can prevent hepatitis B after an acute exposure. It is prepared from hyperimmunized donors who have high levels of anti-HBs. This immune globulin is used in individuals with a known blood exposure to an infected individual.
What research is being done?
Active research of hepatitis B is focused on:
New treatments for chronic hepatitis B infection
The development of newer vaccine strategies
The role of HBV in liver cancer
Treatments for individuals with chronic hepatitis B infection, but who have normal liver blood tests, and are at a high risk of liver cancer
Links to other information
For more information on hepatitis B, log on to the following Web sites:
CDC Web site
NIDDK Web site
Hepatitis Foundation International Web site
American Liver Foundation Web site
American Digestive Health Foundation Web site
References
Sokal EM, Conjeevaram HS, Roberts EA, et al. Interferon alfa therapy for chronic hepatitis B in children: a multinational randomized controlled trial. Gastroenterology 1998;114:988-95.
Chang MH, Chen CJ, Lai MS, et al. Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. N Engl J Med 1997;336:1855-9.
Lee PI, Lee CY, Huang LM, Chang MH. Long-term efficacy of recombinant hepatitis B vaccine and risk of natural infection in infants born to mothers with hepatitis B e antigen. J Pediatr 1995;126:716-21.
Lemon SM, Thomas DL. Vaccines to prevent viral hepatitis. N Engl J Med 1997;336:196-204.
Hoofnagle JH, di Bisceglie AM. The treatment of chronic viral hepatitis. N Engl J Med 1997;336:347-56.
Balistreri WF. Acute and chronic viral hepatitis. In: Suchy FJ, ed. Liver disease in children. St. Louis: Mosby, 1994:460-509.
About the Author
Dr. Narkewicz graduated from the University of Vermont School of Medicine and completed his training in Pediatrics and Pediatric Gastroenterology at the University of Colorado.
He holds the Hewit-Andrews Chair in Pediatric Liver Disease and is Associate Professor of Pediatrics at the University of Colorado and the Medical Director of the Pediatric Liver Center and Liver Transplantation at The Children’s Hospital, Denver, Colorado.
Copyright 2012 Michael Narkewicz, M.D., All Rights Reserved
Hepatitis B vaccines
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html
Hepatitis C
What is hepatitis C?
How does HCV cause disease?
Who gets hepatitis C?
What happens to children with hepatitis C?
It turns out that my baby is not infected; what is “passive transfer of antibody”?
How is hepatitis C diagnosed?
What will doctors do for me if I have hepatitis C?
Is there any treatment for hepatitis C?
What are the complications of hepatitis C?
Can I spread HCV to people around me?
Knowing that I have hepatitis C, is there anything I should do?
What is being done for prevention of hepatitis C?
What research is being done?
Links to other information
Latifa T.F. Yeung, M.D., FRCPC
Research Fellow, Division of Pediatric Gastroenterology and Nutrition
University of Toronto, The Hospital for Sick Children
Toronto, Canada
and
Eve A. Roberts, M.D., FRCPC
Professor of Pediatrics, Medicine, and Pharmacology
University of Toronto, The Hospital for Sick Children
Toronto, Canada
What is hepatitis C?
Hepatitis C is an infection of the liver caused by a virus called “hepatitis C virus” (HCV), an RNA virus. Before this virus was identified (in 1989), many cases of hepatitis C infection were simply termed “non-A non-B hepatitis” (NANBH).
How does HCV cause disease?
HCV may damage liver cells directly, or liver cells may get damaged when the body’s immune system fights the virus. The immune system often has trouble eliminating the virus because HCV is very sneaky; it constantly changes parts of its protein structure (forming “quasi-species”) so that the human immune system cannot fight it effectively. By evading the immune system, HCV causes long-term (chronic) infection of the liver with low-grade liver cell damage (chronic hepatitis).
Who gets hepatitis C?
HCV is spread by infected blood and body fluids. Many cases of hepatitis C are likely from transfusion of contaminated blood products. Intravenous drug use is an important way by which one might acquire HCV infection. High-risk sexual behaviors may lead to transmission of HCV. Vertical transmission of HCV from mother to child during pregnancy or delivery also may occur.
What happens to children with hepatitis C?
Compared to adults, children tend to have a shorter duration of infection. Thus, their disease tends to be milder, and they usually feel fine. However, doctors worry that in time children with hepatitis C infection will develop severe liver damage and scarring. On the other hand, some children seem to have cleared their infection without any treatment. There is still a lot to learn about how this disease affects children.
It turns out that my baby is not infected; what is “passive transfer of antibody”?
During pregnancy, mothers pass their antibodies to their babies. These antibodies are meant to protect the baby until his/her own antibodies can develop. It is expected that maternal antibodies of HCV disappear within the baby’s first 18 months of life.
How is hepatitis C diagnosed?
Most people find out they have hepatitis C after blood testing finds that they have antibodies to the virus (anti-HCV), which shows that the immune system has been exposed to the virus. At this point, further testing is done (see What will doctors do for me if I have hepatitis C?).
What will doctors do for me if I have hepatitis C?
Children with hepatitis C infection need to be monitored. Each time your child is seen in a clinic, your child will be asked about how he/she is feeling and be examined. Blood tests are helpful to see how your child’s liver is doing. Blood testing also can look for antibodies to the virus (anti-HCV), which reflect the body’s exposure to the virus. Testing for the actual virus (HCV RNA) also may be done.
Your doctor may suggest that a liver biopsy be performed; this procedure involves taking a tiny sample of your child’s liver so that it may be analyzed under the microscope. The liver biopsy is the most direct way of seeing if there is significant liver damage.
Is there any treatment for hepatitis C?
Interferon-alpha is given by injection regularly for 6 to 12 months to try to cure the infection. In adults, this drug works initially in some patients; however, many patients relapse after the drug is sped, and the hepatitis C infection comes back. In most patients, treatment with interferon-alpha fails. This drug has side effects that are similar to flu-like symptoms. Patients taking interferon-alpha need to be monitored carefully.
Recently, it has been learned that two drugs are better than one. Ribavirin, combined with interferon-alpha, appears to cure around 30% to 50% of adults with chronic hepatitis C. Ribavirin is taken by mouth once or twice a day. It also needs to be taken for a long time, usually for as long as the interferon-alpha is given. The combination of ribavirin and interferon-alpha is being tested in children.
Decisions to treat HCV infection should be discussed with us. The currently available treatments take a long time and demand a strong commitment. In addition, the success rates are mediocre. Efforts are ongoing to find better combinations of drugs that will be more effective at curing chronic hepatitis C.
What are the complications of hepatitis C?
Although most people do not feel sick (i.e., they are asymptomatic), HCV causes damage to the liver over a long period of time. Chronic hepatitis can lead to scarring of the liver (cirrhosis) and eventually make the liver not function well. The scarring of the liver also has been associated with a higher risk of liver cancer. In North America, chronic hepatitis C is now the number one reason for liver transplantation in adults.
Can I spread HCV to people around me?
Exposure to blood contaminated with HCV is by far the most efficient means of spreading HCV. In contrast, the spread of HCV from casual contact is very unlikely. Transmission of HCV from sexual contact may occur, so precautions are necessary.
Knowing that I have hepatitis C, is there anything I should do?
People with hepatitis C infection can get sicker than most people if they get an additional form of hepatitis. Thus, people with chronic hepatitis C should receive vaccination for hepatitis A and B.
Alcohol makes any liver disease worse. It makes chronic hepatitis C much worse. Patients with hepatitis C infection are advised to abstain from alcohol (even “social drinking”).
Preventing spread of infection is an important public health issue. The sharing of personal hygiene items, such as razors and toothbrushes, should be avoided. It would be reasonable to beware of spreading HCV infection through sharing of other objects that might have contaminated blood (e.g., needles used in ear or body piercing, tattooing, or nail clippers). Teens who are sexually active should practice responsible and safe sex.
What is being done for prevention of hepatitis C?
Blood products are now screened for HCV by multiple effective methods. The risk of getting hepatitis C from a blood transfusion is very low. Although there is ongoing research to make a vaccine for HCV (which could protect people from getting infected), this work faces such challenges as the HCV quasi-species problem; the constantly changing virus makes it hard to perfect a vaccine.
What research is being done?
Researchers are studying the virus to figure out how it infects cells and lives in them. In doing so, better drugs can be made to kill the virus or to help boost the patient’s immune system to fight off HCV. To develop effective prevention and treatment strategies for HCV infection, researchers must know what would happen if the disease was allowed to play itself out, without any treatment. That is, researchers are trying to work out the “natural history” of the chronic hepatitis C infection.
Links to other information
Centers for Disease Control and Prevention http://www.cdc.gov/
Canadian Liver Foundation http://www.liver.ca/
Canadian Pediatric Society Statement on Vertical Transmission of HCV www.cps.ca
References
Cohen J. The scientific challenge of hepatitis C. Science 1999;285:26-30.
Alter MJ, Kruszon-Moran D, Nainan OV, et al. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. New Engl J Med 1999;341:556-62.
Cerny A, Chisari FV. Pathogenesis of chronic hepatitis C: immunological features of hepatic injury and viral persistence. Hepatology 1999;30:595-601.
Ahmed A, Keeffe E. Treatment strategies for chronic hepatitis C: update since the 1997 National Institutes of Health Consensus Development Conference. J Gastroenterol Hepatol 1999;14 Suppl:S12-8.
Rosenthal E, Hazani A, Segal D, et al. Lack of transmission of hepatitis C virus in very close family contacts of patients undergoing multitransfusions of thalassemia. J Ped Gastro Nutr 1999;9:101-3.
About the Author
Dr. Yeung obtained her M.D. from the University of Toronto and completed her training in pediatrics at the Hospital for Sick Children in Toronto, Canada. She is currently a research fellow in the Division of Pediatric Gastroenterology and Nutrition at the Hospital for Sick Children. Her research focuses on hepatitis C infection in children.
Dr. Roberts obtained her M.D. from the Johns Hopkins University School of Medicine and trained in hepatology at The Royal Free Hospital under Professor Dame Sheila Sherlock. She is currently a professor of pediatrics, medicine, and pharmacology at the University of Toronto and the Hospital for Sick Children.
Copyright 2012 Latifa T.F. Yeung, M.D., FRCPC, All Rights Reserved
HIB Immunization
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hib.html
High Blood Pressure
What is hypertension?
Table: Levels of Severe Hypertension (95th Percentile) for Boys and Girls
What causes hypertension?
How is secondary hypertension diagnosed?
How is childhood hypertension treated?
What is the goal of hypertension treatment?
Albert P. Rocchini, M.D.
Professor of Pediatrics
University of Michigan
What is hypertension?
An elevated blood pressure level in a child is defined as a blood pressure that is above the 90th percentile for age and sex. Although the finding of an elevated blood pressure on physical examination constitutes an abnormal sign, it does not mean that hypertension (i.e., sustained blood pressure elevation) is persistent. Most pediatricians recommend that for a child to be diagnosed with hypertension the blood pressure must be abnormal (above the 95th percentile rank of age and sex) on at least 3 separate examinations over a 6- to 12-month interval (see table). The only exception is if at the time of the initial examination the child has signs and/or symptoms commonly found with severe hypertension (e.g., heart muscle enlargement, headache, dizziness, seizures, eye and vision damage).
Table: Levels of Severe Hypertension (95th Percentile) for Boys and Girls
Boys Girls
Age (years) Systolic BP Diastolic BP Systolic BP Diastolic BP
1 105 59 104 58
6 112 73 115 75
12 124 81 125 82
17 130 85 136 88
What causes hypertension?
Once a child is diagnosed with hypertension, its cause must be determined. The two major types of hypertension are as follows:
Essential hypertension Essential hypertension (i.e., without any identifiable cause) occurs in 50% to 60% of children with hypertension. The majority of these children will be obese.
Secondary hypertension The common causes of secondary hypertension include renal (kidney) disease, cardiovascular (heart and vessel) disease, endocrine (hormone or metabolism) disorders, and other miscellaneous conditions.
How is secondary hypertension diagnosed?
A thorough history and physical examination is essential in evaluating a child with secondary hypertension
In the history, the following significant points should be addressed:
Symptoms suggesting associated disease (e.g., unexplained fever – in kidney infection; leg pains with exercise – in coarctation of the aorta [see Coarctation of the Aorta article]; weight loss and tremor – in hyperthyroidism; sweating, night terrors, and palpations – in an adrenal gland tumor)
Medications or chemicals that can raise the blood pressure (e.g., birth control pill, steroids, amphetamines)
Any history of trauma
The physical examination should include the following:
Blood pressure and pulse should be taken in both the upper and the lower extremities. (A difference in pressure and pulse between the arms and the legs is diagnostic of coarctation of the aorta.)
A careful abdominal examination should be performed to detect masses (e.g., polycystic kidney disease, where the kidneys are too large because of multiple cysts; tumors) and abnormal pulses (e.g., renal artery stenosis, where the vessels supplying blood to the kidneys are abnormally narrow).
A careful examination of the skin should be performed (e.g., cafe-au-lait spots or brownish spots in neurofibromatosis, striae or skin stretch marks, hirsutism or male hair growth pattern of Cushing’s syndrome).
A thorough eye examination should be performed.
The only routine laboratory tests that should be performed are as follows: urine dipstick, blood electrolytes, blood urea nitrogen, and creatinine. Other laboratory tests should be ordered based on both the history and the physical examination.
How is childhood hypertension treated?
All children with significant, sustained hypertension should be treated. The treatment of hypertension is divided into two major categories: hypertensive crisis and chronic hypertension.
. Hypertensive crisis Hypertensive crisis is defined as life-threatening hypertension that is associated with hypertensive encephalopathy (changes in the brain and neurologic function due to the increased blood pressure) and/or acute heart failure. The calcium-channel blockers amlodipine and nifedipine are very effective in treating hypertensive crisis. Other medications used include diazoxide, nitroprusside, and minoxidil. No matter what medication is used, once acute blood pressure reduction is achieved, other medicines need to be added to maintain long-term blood pressure control.
. Chronic hypertension The ideal therapy for chronic hypertension is to treat, if possible, the underlying disease that is responsible for the hypertension. If this is not possible, then nonpharmacologic (not using medications) and pharmacologic (using medications) intervention is needed.
Nonpharmacologic treatment Dietary management should be the initial form of therapy in all children with hypertension. Weight loss is the treatment of choice for the obese adolescent with essential hypertension. Lowering salt intake also can be helpful. In addition to dietary management, other nonpharmacologic therapies include quitting smoking, not taking oral contraceptive pills and other vasoactive drugs, and avoiding heavy alcohol consumption. Daily physical activity should be encouraged.
Pharmacologic treatment In pediatric patients, the first line of antihypertensive medications are angiotensin converting enzyme inhibitors and calcium channel blockers. The most common side effect of angiotensin converting enzyme inhibitors is a chronic cough. If a chronic cough requires the child to s taking the converting enzyme inhibitor, an alternate therapy is angiotensin receptor antagonists. The most common side effects of calcium channel blockers are a rapid heart rate and fluid retention.
Until recently, diuretics and beta-blockers were the most commonly used drugs to treat childhood hypertension. However, most pediatricians are now reluctant to use them because of evidence suggesting that these agents may adversely affect plasma lipids and insulin sensitivity. Beta-blockers also can cause depression and impair school performance.
Other antihypertensive agents used to treat refractory hypertension include centrally-acting drugs (e.g., Clonidine, Guanabenz), alpha-blockers, and vasodilators (e.g., hydralazine, minoxidil).
What is the goal of hypertension treatment?
The goal of therapy is to keep the child’s blood pressure below the 90th percentile for age and sex. Parents must be taught not only to monitor their child’s blood pressure at home, but also to monitor for signs of medication-induced side effects.
Successful therapy should not interfere with the child’s academic performance, involvement in sports, or interest in social activities. Participation in team sports should be encouraged unless there is clear evidence of heart dysfunction.
Once the child’s blood pressure is under good control, the child should be evaluated (at least) on an annual basis to assess cardiac status, physical growth and development, and sexual maturation patterns.
References
Report of the Second Task Force on Blood Pressure Control in Children. Pediatrics 1987;79(1):1-25.
Sinaiko AR. Pharmacologic management of childhood hypertension. Pediatr Clin North Am 1993;40(1):195-212.
Falkner B. Management of hypertensive children and adolescents. In: Izzo JL, Black HR, eds. Hypertension primer: the essentials of high blood pressure. 2nd ed. American Heart Association, 1999:424.
About the Author
Dr. Rocchini received both his bachelor of science degree in chemical engineering and his medical degree from the University of Pittsburgh. He completed his pediatric residency at the University of Minnesota and his pediatric cardiology fellowship at the Children’s Hospital of Boston. Dr. Rocchini is currently a professor of pediatrics and serves as director of pediatric cardiology at the University of Michigan. His research interests include interventional cardiac catheterization and obesity-induced hypertension.
Copyright 2012 Albert P. Rocchini, M.D., All Rights Reserved
HIV/AIDS
What is HIV/AIDS?
What causes HIV/AIDS?
Who gets HIV/AIDS?
How does HIV cause disease?
What are the common findings?
How is HIV/AIDS diagnosed?
How is the HIV infection treated?
What are the complications?
How is HIV prevented?
What research is being done?
Links to other information
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
by Elizabeth J. McFarland, M.D.
University of Colorado Health Sciences Center
Denver, CO
What is HIV/AIDS?
Acquired immunodeficiency syndrome (AIDS) is a condition in which the immune system has lost the ability to defend the body against infection and certain cancers. It is caused by infection with human immunodeficiency virus (HIV).
What causes HIV/AIDS?
The cause of AIDS is infection with HIV. HIV is a member of the family of viruses called retroviruses. This type of virus enters human cells and becomes incorporated into the cell’s genes (i.e., DNA). Once the infection has occurred, the body cannot rid itself of the virus. The effect of the virus on the immune system leads to AIDS.
Who gets HIV/AIDS?
HIV/AIDS affects people of all ages and racial/ethnic backgrounds. Usually, infants and children acquire the infection from the mother during pregnancy, delivery, or breastfeeding. The most common mode of transmission for teens and adults is sexual contact. Currently, the largest number of HIV-infected people lives in Africa, India, and Southeast Asia. In the United States, homosexual men and injecting drug users have the highest prevalence of infection. However, adolescents and women, particularly those of African-American and Hispanic background, have the highest rates of new infections.
Casual, classroom, or household contact with an HIV-infected person poses no risk. Transmission cannot occur from sharing dishes, towels, or bathroom facilities. Saliva, urine, and stool are not contagious unless there is visible blood in the fluid.
HIV is transmitted through contact with infected semen or cervical secretions. People who have sexual contact with an infected person are at risk of acquiring the infection. The virus can be transmitted by both heterosexual and homosexual contact. Men and women, adults and teenagers can become infected with HIV.
HIV is transmitted from mother to infant during pregnancy, delivery, and breastfeeding. An infected woman who does not receive treatment during pregnancy has a 25% to 30% chance of passing the virus on to her baby. With treatment, the chance of having an infected baby can be reduced to 1%.
HIV is transmitted through contact with infected blood or body fluids contaminated with visible blood. Donated blood is screened for HIV so there is almost no risk of an infection from blood transfusion products. However, people who use injection drugs sometimes share their injection equipment. If an HIV-infected person shares a needle or other injection equipment, the virus can be transmitted to the other people. A health care professional who is exposed to blood from an infected person has a risk of being infected with HIV. This risk is greatest when a contaminated sharp instrument penetrates the skin. There also is a small risk of infection when blood splashes into the eye or the mouth of the worker. There is no risk of infection with blood contact to intact skin (i.e., skin without cuts, scratches, or a rash). Under usual circumstances, there is no risk of transmission of HIV from a health care professional to a patient. However, all people should handle blood and bloody body secretions carefully.
How does HIV cause disease?
HIV infection, without treatment, causes a progressive dysfunction of the immune system. When the immune system is defective, the body cannot defend itself against infections. HIV infects immune cells that are critical components of the immune system, particularly helper T lymphocytes (T4 cells). When the cells are infected with HIV, they do not function normally, and some cells are destroyed.
What are the common findings?
Teens and adults may have symptoms in the first two to six weeks after the initial infection with HIV (acute primary infection). The most common symptoms of the primary infection are fever, fatigue, muscle aches, headache, sore throat, and swollen lymph nodes (glands in the neck, under the arms, and in the groin). These symptoms are not specific to HIV infection since many viral infections cause similar symptoms. Some other symptoms more particular to primary HIV infection are mouth ulcers, a rash, and meningitis. However, even these symptoms do not prove HIV infection because they can occur with other infections. Some people have no symptoms after the acute infection. The symptoms of the primary infection resolve without treatment. Most people do not seek medical attention, and they are not aware that they have acquired HIV.
After the primary infection, most people infected with HIV have no symptoms in the early stages of the disease. For adults and adolescents, progression of the disease usually occurs several years after the primary infection. About 30% of infants infected at birth will have disease progression within 12 to 18 months of life.
When the disease progresses, common first symptoms include enlargement of the lymph nodes, liver, and/or spleen; poor growth; frequent minor infections, such as ear infections and sinusitis; cold sores that do not heal; thrush or diaper rash that persists despite treatment; shingles; night sweats; and recurrent fever. When the disease reaches advanced stages, most patients have weight loss; infections of the lungs, blood stream, bones, joints, intestines, and eyes; and certain cancers. Some people develop neurologic symptoms manifested by developmental delay in children and by memory loss and dementia in teens and adults.
How is HIV/AIDS diagnosed?
The most commonly used diagnostic test for HIV infection detects antibodies to HIV in the blood. The body makes antibodies as a part of the immune defense against infections. If antibodies against HIV are present (a “positive” test), this indicates that the person is infected with HIV. This is why infected people are called “HIV positive.”
The antibody test is done in two parts. The first part is called an ELISA. Occasionally, a person will test positive on an ELISA even though they are not HIV infected. Therefore, a positive ELISA test must have a confirmatory test done on the same blood sample showing that the antibodies are truly specific for HIV. A negative ELISA indicates that the person is not infected and usually does not require a follow-up test.
In some patients, antibody tests are not reliable. In this case, tests that directly detect the virus are used. The most commonly used tests detect the virus genetic material (DNA or RNA) or protein (p24 antigen) in the blood. Virus tests are used to diagnose HIV infection in infants born to HIV-infected mothers. Antibody tests on the baby are not reliable until after 18 months of age because all mothers will pass antibodies to their babies, but not all mothers will pass the virus. In order to determine if the infant is infected, tests to detect the virus in the baby’s blood are performed. The majority of infected infants will have the virus detected by three to four months of life. Uninfected infants will have negative tests for the virus (even though their antibody test is positive).
Direct virus testing also is used for adults and teenagers who may have been recently exposed to HIV. The virus tests are positive about 10 to 14 days before the antibody tests are positive. Using the direct virus test permits an earlier diagnosis of infection.
How is the HIV infection treated?
Recently, many new medications have been developed to treat HIV infection. These medications are called anti-retroviral drugs, and they inhibit the replication or reproduction of the virus. Effective treatment requires a combination of several different anti-retroviral medications, taken by mouth, one to three times a day. The amount of virus in the blood and the number of helper T cells are monitored closely to determine whether the medications are effective. Although there is no cure for HIV/AIDS, with effective treatment, infected people may live for years without disease progression.
What are the complications?
The complications of HIV infection are primarily related to immune dysfunction. Immune dysfunction leads to infection with other bacteria, viruses, or fungi. Medications can be taken daily or weekly to prevent these infections. In some patients, HIV causes abnormal function of the heart, bone marrow, brain, muscles, intestines, liver, and pancreas.
How is HIV prevented?
The most important method to prevent HIV infection is to avoid exposure by sexual contact. Abstinence is the only certain way to avoid sexual exposure to HIV. The risk of transmission can be greatly reduced by the correct use of condoms during sexual contact. Individuals who do have sexual contact should limit their number of partners and use condoms correctly every time they have sexual contact.
Sharing contaminated needles can transmit HIV. Injection drug users should not share injection equipment. Children should be taught to avoid contact with other people’s blood. They also should avoid sharing sharp personal objects (e.g., razors, body-piercing equipment), which may be contaminated by blood and have not been properly sterilized. When caring for a bleeding wound, a thick layer of paper or cloth should be used to reduce the chances of contact with the blood.
Over 95% of infections passed from mother to infant can be prevented if the mother and infant receive treatment during pregnancy, labor, and the first weeks after birth. All women should be offered testing for HIV during pregnancy so they can receive the preventative treatments if they are HIV positive.
What research is being done?
Research on the treatment and prevention of HIV infection is very active. The areas of most intense interest are the development of a vaccine to prevent infection, the development of improved anti-retroviral medications, and studies to understand how the body’s immune defenses against HIV infection can be enhanced.
Links to other information
http://www.fxbcenter.org/Sponsor: The Francois-Xavier Bagnoud Center, University of Medicine and Dentistry of New Jersey, The National Pediatric and Family HIV Resource Center (NPHRC). This Web site includes extensive information about HIV that is related to children and youth.
http://www.kidsconnect.org/porch/This Web site includes information about HIV that is written at a child’s level.
http://hivinsite.ucsf.edu/InSite?page=li-06-05This Web site includes information about HIV that is both focused on youth and written in youth-friendly terms.
About the Author
Dr. McFarland is the medical director and co-founder of the Children’s Hospital Immunodeficiency Program (CHIP) in Denver, CO. CHIP provides comprehensive health care to infants, children, adolescents, young adults and pregnant women infected or affected by HIV.
Dr. McFarland is a member of the National Institutes of Health sponsored Pediatric AIDS Clinical Trial Group and is active in basic and clinical HIV research. She is board certified in Pediatric Infectious Diseases and a faculty member at the University of Colorado Health Sciences Center.
She received her MD degree from Duke University School of Medicine and her pediatric and subspecialty training from the University of Colorado Health Sciences Center.
Copyright 2012 Elizabeth J. McFarland, M.D., All Rights Reserved
Hyperactivity
The Facts About ADHD
What is ADHD?
What causes ADHD?
How is ADHD diagnosed?
How is ADHD treated?
What research is being done?
Other Information
Sam Goldstein, Ph.D.
Neurology, Learning and Behavior Center
University of Utah
Salt Lake City, Utah
The Facts About ADHD:
Attention-Deficit Hyperactivity Disorder (ADHD) is characterized by inattentive, hyperactive, and impulsive behavior. These problems are often inappropriate and cause difficulty in daily life. ADHD is a “biopsychosocial” disorder. That is, there appear to be strong genetic, biological, life experience, and social factors that contribute to the extent of problems. ADHD affects 3% to 5% of individuals throughout their life. Early identification and proper treatment dramatically reduces the family, educational, behavioral, and psychological problems experienced by individuals with ADHD. It is believed that through accurate diagnosis and treatment, these problems-including school failure and dropout, depression, behavioral disorders, vocational and relationship problems, and substance abuse-can be properly managed or even avoided.
At one time, it was thought that the symptoms of ADHD lessen by adolescence. Research has now found that the majority of individuals with ADHD become adults with a very similar pattern of problems. Adults with ADHD experience problems at work, in the community, and in their families. They also exhibit a greater degree of emotional problems, including depression and anxiety.
Researchers first described the inattentive, hyperactive, and impulsive problems of children with ADHD in 1902. Since that time, the disorder has been referred to by different names, including Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, Attention Deficit Disorder, and, currently, Attention-Deficit Hyperactivity Disorder.
What is ADHD?
ADHD interferes with an individual’s ability to stay attentive, particularly in the face of repetitive tasks; to manage effectively emotions and activity level; to respond consistently to consequences; and, perhaps, most importantly, to inhibit, i.e., to s from doing something. Individuals with ADHD may know what to do, but do not do what they know, because they are unable to s and think prior to responding, regardless of the setting or the task.
Characteristics of ADHD occur in early childhood for most individuals. Chronic behaviors last at least six months, with an onset often before seven years of age.
Four subtypes of ADHD have been defined. The first type is ADHD-Inattentive Type, and is defined by an individual experiencing at least six of the following characteristics:
Fails to give close attention to details or makes careless mistakes
Difficulty sustaining attention
Does not appear to listen
Struggles to follow through on instructions
Difficulty with organization
Avoids or dislikes tasks requiring sustained mental effort
Often loses things necessary for tasks
Easily distracted
Forgetful in daily activities
The second type is ADHD-Hyperactive/Impulsive Type, and is defined by an individual experiencing six of the following characteristics:
Fidgets with hands or feet, or squirms in seat
Difficulty remaining seated
Runs around or climbs excessively (In adults, it may be limited to subjective feelings of restlessness.)
Difficulty engaging in activities quietly
Acts as if driven by a motor
Talks excessively
Blurts out answers before questions have been completed
Difficulty waiting in turn-taking situations
Interrupts or intrudes upon others
The third type is ADHD-Combined Type, and is defined by an individual meeting both the inattentive and the hyperactive/impulsive criteria.
The fourth type is ADHD-Not Otherwise Specified, and is defined by an individual who shows some characteristics, but an insufficient number of symptoms to reach a full diagnosis. These symptoms, however, disrupt daily life.
School-age individuals with ADHD have a greater likelihood of not advancing to the next grade level, school dropout, academic underachievement, and social and emotional problems. It has been suggested that the symptoms of ADHD may cause children to fail in two of the most important areas for their development-school and peer relationships.
With increasing medical, educational, mental health, and community knowledge about the symptoms of and the problems caused by ADHD, an increasing number of individuals are being identified, diagnosed, and treated. Nonetheless, it is still suspected that a significant group of individuals with ADHD either go undiagnosed or misdiagnosed. Their problems intensify and create significant hurdles meeting life’s demands.
Often, ADHD has been inaccurately portrayed as a learning disability. ADHD is a performance disorder. Children with ADHD are able to learn, but they have difficulty performing in school due to the impact of the ADHD symptoms. However, approximately 20% to 30% of children with ADHD do have a learning disability, which makes the identification and treatment of ADHD more difficult. In the childhood years, individuals with ADHD also have an increased risk of developing problems related to oppositional defiance, delinquency, conduct disorder, depression, and anxiety. However, research suggests that it is not ADHD alone, but rather ADHD combined with the development of conduct disorder that may cause the most terrible adolescent outcomes, particularly those related to criminal behavior and substance abuse.
Adults with ADHD also experience problems related to anti-social behavior, vocational and educational underachievement, depression, anxiety, and substance abuse. Unfortunately, many adults, today, with ADHD were not properly diagnosed as children. They grew up struggling with a disability that often went undiagnosed, misdiagnosed, or untreated.
The majority of adults with ADHD have symptoms very similar to those experienced by children. They are restless, easily distracted, inattentive, impulsive, and impatient. Often, they are unable to handle stress. Within the workplace, they may not achieve positions or status equal to that of their siblings or intellectual ability.
What causes ADHD?
Commonly suspected causes of ADHD have included toxins, developmental impairments, diet, injury, ineffective parenting, and heredity. It has been suggested that these potential causes affect brain functioning; thus, ADHD is considered a disorder of brain function. A number of studies have shown significant differences in the structure and brain function of individuals with ADHD, particularly in the right hemisphere of the brain, pre-frontal cortex, basal ganglia, corpus callosum, and cerebellum. These structural and metabolic studies, combined with family, genetic, and drug response studies, have indicated that ADHD is a neurobiological disorder. Though the severity of problems experienced by individuals with ADHD may vary based upon life experience, genetics appears to be the primary underlying factor in determining if an individual will show the symptoms of ADHD.
How is ADHD diagnosed?
Diagnosing ADHD is a multifaceted process. Many biological and psychological problems can cause symptoms similar to those shown by individuals with ADHD. For example, inattention is a symptom of depression. Impulsive behavior is a characteristic sign of delinquency.
A comprehensive evaluation is necessary to diagnose ADHD, in addition to considering and evaluating other causes, and determining the presence or absence of other conditions. Obtaining a careful life history is the most important aspect in diagnosing ADHD. Often, an evaluation for ADHD will assess intellectual, academic, social, and emotional functioning. A medical examination is important to rule out other possible causes of ADHD-like symptoms (e.g., adverse reaction to medications, thyroid problems, etc.). The diagnostic process must include gathering information from teachers and other adults who interact routinely with the individual being evaluated. Although office- or laboratory-based paper and pencil, problem solving, and computerized tasks are popular in assessing ADHD, researchers are evaluating their validity.
With adults, it is even more important to obtain a careful history of childhood, academic, behavioral, and vocational problems. Since ADHD has been recognized as a disorder that occurs throughout life, questionnaires and other related tools for diagnosing ADHD in adults have been standardized and are available.
How is ADHD treated?
Treating ADHD in children requires a coordinated effort between medical, mental health, and educational professionals, with the parents. The combined set of treatments offered by various individuals is referred to as “multi-modal intervention.” A multi-modal treatment program for ADHD should include the following:
Parental training about ADHD and effective behavior management strategies
An appropriate educational program
Individual and family counseling, when needed, to minimize family problems
Medication, when required
Psychostimulants are the most widely used medications to manage ADHD symptoms. At least 70% to 80% of children and adults with ADHD respond positively to psychostimulant medications. These medications are considered performance enhancers. Thus, they may, to some extent, stimulate the performance of all individuals. However, given their specific problems, children with ADHD appear to improve, with a reduction in impulsive and hyperactive behavior and an increase in attention span.
Behavior management is important for children with ADHD. The use of positive reinforcement with punishment, in a model referred to as “response cost,” is particularly effective for children with ADHD.
Most children with ADHD can be taught in a regular classroom with minor adjustments in the classroom setting, the addition of support personnel, and/or special education programs provided outside of the classroom. The most severely affected children with ADHD often require specialized classrooms.
Adults with ADHD may benefit from learning to structure their environment; to develop organizational skills; to receive vocational counseling; and, if needed, to have short-term psychotherapy to cope with life experiences and personal problems. For some individuals, with a combination of ADHD and other problems, particularly depression, long-term psychotherapy can be beneficial to teach behavior change and coping strategies.
ADHD treatments are effective in reducing immediate, symptomatic problems. However, the long-term outcome research for children with ADHD has led researchers to conclude that symptom relief alone may not significantly impact the long-term outcome. Thus, ADHD treatments are provided to relieve symptoms, while efforts also are made to assist the ADHD individual in building life success.
To help parents in treating their ADHD child, a nine-point set of strategies is outlined below (Goldstein and Goldstein, 1998).
Step 1: Learn About ADHD. It is important to understand that managing ADHD-driven behavior at home requires accurate knowledge of the disorder and its complications. This is not a problem that can be cured. It will affect children throughout their life. You must be consistent, predictable, and supportive of a child in daily interactions. You will be repeatedly placed in an advocacy position with schools and community resources. It is suggested that you consider joining a parent support organization directed at ADHD.
Step 2: Understanding Incompetence vs. Non-Compliance. You must distinguish between problems that result from incompetence and those that result from non-compliance. The former must be dealt with through education and skill building. The latter is usually quite effectively dealt with through consequences. You must understand that punishing a child for symptoms of ADHD may lead to remorse and a promise of better behavior, but stands little chance of changing behavior in the future.
You must develop a set of strategies to deal with ADHD symptoms by making tasks interesting, payoffs more valuable, and increasing consistency at home, while providing a consistent set of punishments for non-compliant behavior. The best way of dealing with non-compliance is to make certain that you have control over consequences, issue appropriate commands, manage rewards, and use response cost techniques.
Step 3: Give Positive Directions. You must make certain that positive, rather than negative, directions are given. A positive direction tells the child what to begin doing, rather than focusing on what to s doing. Such directions are clear (e.g., “please begin your math homework”), rather than vague (e.g., “pay attention”). The need for repeated trials cannot be overemphasized. You serve as a control system for your child. Your child is going to require more management and supervision in an appropriate, consistent, affirmative way than other children.
Step 4: Provide Ample Rewards. You must provide ample rewards for appropriate behavior. Social and tangible rewards must be provided more frequently when an ADHD child succeeds. Children with ADHD also require more immediate, frequent, predictable, and consistently applied consequences. It is important for the child to learn to consistently act when expected behaviors are required. Most children with ADHD know how to do what is requested, but have difficulty doing so when they are supposed to. Children with ADHD also have been found to receive less positive reinforcement than their siblings.
It is important to avoid negative reinforcement. This only results in removing the negative consequences when the child complies. This often leads to immediate compliance, but, in the long run, it reinforces, rather than discourages, inappropriate behavior.
Token systems, which are particularly effective for children and early teens with ADHD, should be used. Often, token systems fail at home, not because they are ineffective, but because they can be cumbersome and then poorly managed. Tokens should be used with children who are four to seven years old, and points with those children who are eight years and older. Required activities should be kept to a reasonable length, and an extensive list of reinforcers should be available, with at least one third of points or tokens available each day. Children should be able to spend about two thirds of points or tokens earned each day. Bonuses should be paid for a good attitude. You should always allow your children to earn their way off a system through compliant behavior, but a minimum of six to eight weeks on a token system, once it is initiated, should be required.
Step 5: Choose Your Battles. You should choose your battles carefully. While it is essential for you to stay one step ahead, it also is important for you to recognize and accept the difficulties that your child experiences due to ADHD. You should reinforce positive behavior, apply immediate consequences for behaviors that cannot be ignored, and use tokens or points with ADHD children. Consequences, both rewards and punishments, should be provided quickly and consistently.
Step 6: Use Response Cost Techniques. You must understand the use of response cost, a punishing technique in which you might lose what you have earned. If a give and take response cost system is used, you must make certain the child does not go bankrupt. It may be equally effective, especially with older children and teens, to start with the entire payoff and then have the individual work to keep it. For example, instead of providing the child with a $5 allowance at the end of the week when she behaves appropriately, parents may place $5 in nickels in a jar on the shelf that is visible to the child. As long as the child behaves appropriately, the $5 belongs to the child. For every infraction that has been clearly defined and agreed upon between the parents and the child, a nickel is removed from the jar. At the end of the week, the remaining amount is given to the child.
Step 7: Plan Appropriately. You must learn to respond to the child’s limits in a proactive way. Accepting the diagnosis of ADHD means accepting the need to make changes in the child’s environment. Routines should be consistent and rarely vary. Rules should be stated clearly and concisely. Activities or situations in which the child has a history of risk for problems should either be avoided or carefully planned.
Step 8: Punishing Appropriately. Most likely, punishment alone will not reduce the symptoms of ADHD. However, punishment does play a role as a consequence for non-compliant behaviors. Punishment also is partially appropriate if a rule is violated, even as the result of ADHD. However, in this circumstance, punishment must not be provided alone, because it will not change the child’s long-term behavior. For a child with ADHD, you must understand that unless a managing strategy is provided along with punishment, it is not likely that the punishment will cause a change in behavior.
Step 9: Building Islands of Competence. Because of your child’s ADHD, there is a greater likelihood that the relationship between you and your child will be strained. However, in the end, it is what is right about children, rather than what is wrong about them, that best predicts their life outcome. Increasingly, the mental health field is focusing on building strengths, rather than attempting to hammer away at weaknesses. One of the best predictors of building strengths is the parents’ relationship with their child. If you approach each day with a sense of hope, encouragement, acceptance, and honesty, you will empower your child. If you approach each day with a sense of despair, discouragement, anger, and blame, you will not only jeopardize your child’s future, but also further feed their sense of powerlessness and hopelessness.
What research is being done?
Most likely, ADHD will continue to be the most widely researched and debated area in mental health and child development. New ground is broken daily. The five-year, multi-site, multi-modal ADHD treatment study recently completed by the National Institute of Mental Health has provided an expanded set of answers concerning the diagnosis, treatment, and outcome of individuals with ADHD. Ongoing studies of molecular genetics also may soon reliably identify the genes related to this disorder.
Other Information
Organizations, such as CH.A.D.D., 8181 Professional Plaza, Suite 201, Landover, MD 20785, (301) 306-7070, offer parents information, monthly magazines, newsletters, and presentations.
A large trade library of books, videos, and cassette tapes is available for parents, providing accurate information concerning ADHD and research proven effective parenting strategies.
References
Barkley, R.A. (1998). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 2nd edition. New York, NY: Guilford Press.
Barkley, R.A. (1997). ADHD and the Nature of Self-Control. New York, NY: Guilford Press.
DuPaul, G.J. & Stoner, G. (1994). ADHD in the Schools: Assessment and Intervention Strategies. New York, NY: Guilford Press.
Goldstein, S. (1997). Managing Attention and Learning Disorders in Late Adolescence and Adulthood: A Guide for Practitioners. New York, NY: Wiley Interscience Press.
Goldstein, S. & Goldstein, M. (1998). Managing Attention Deficit Hyperactivity Disorder: A Guide for Practitioners, 2nd Edition. New York, NY: Wiley Interscience Press.
Greenhill, L.L. & Osman, B.B. (1991). Ritalin: Theory and Patient Management. New York, NY: Mary Ann Liebert, Inc. Publisher.
Matson, J.L. (1993). Handbook for Hyperactivity in Children. Boston, MA: Allyn & Bacon.
Nadeau, K.G. (1995). A Comprehensive Guide to Attention Deficit Disorder in Adults. New York, NY: Brunner/Mazel Publishers.
About the Author
Sam Goldstein, Ph.D. is a member of the faculty at the University of Utah. He is on staff at Primary Children’s Hospital and the University Neuropsychiatric Institute. Dr. Goldstein has served as Chairman of the National Professional Advisory Board for the organization Children and Adults with Attention Deficit Hyperactivity Disorder and is a member of the Professional Advisory Boards for the Attention Deficit Disorder Association and the National Parenting Instructors Association.
Dr. Goldstein’s publications include articles, guides, book chapters and twelve texts on subjects including genetic and developmental disorders, depression, classroom consultation, learning disability and Attention Deficit Hyperactivity Disorder. His most recent texts include the Handbook of Neurodevelopmental and Genetic Disorders in Children (Guildford, 1998) and Managing Attention Deficit Hyperactivity Disorder in Children – 2nd Edition (Wiley, 1998).
Dr. Goldstein serves as Associate Editor for the Journal of Attention Disorders and is a member of the Editorial Boards of the ADHD Report, Archives of Clinical Neuropsychology and the Journal of Learning Disabilities.
Copyright 2012 Sam Goldstein, Ph.D., All Rights Reserved
Hypertension
What is hypertension?
Table: Levels of Severe Hypertension (95th Percentile) for Boys and Girls
What causes hypertension?
How is secondary hypertension diagnosed?
How is childhood hypertension treated?
What is the goal of hypertension treatment?
Albert P. Rocchini, M.D.
Professor of Pediatrics
University of Michigan
What is hypertension?
An elevated blood pressure level in a child is defined as a blood pressure that is above the 90th percentile for age and sex. Although the finding of an elevated blood pressure on physical examination constitutes an abnormal sign, it does not mean that hypertension (i.e., sustained blood pressure elevation) is persistent. Most pediatricians recommend that for a child to be diagnosed with hypertension the blood pressure must be abnormal (above the 95th percentile rank of age and sex) on at least 3 separate examinations over a 6- to 12-month interval (see table). The only exception is if at the time of the initial examination the child has signs and/or symptoms commonly found with severe hypertension (e.g., heart muscle enlargement, headache, dizziness, seizures, eye and vision damage).
Table: Levels of Severe Hypertension (95th Percentile) for Boys and Girls
Boys Girls
Age (years) Systolic BP Diastolic BP Systolic BP Diastolic BP
1 105 59 104 58
6 112 73 115 75
12 124 81 125 82
17 130 85 136 88
What causes hypertension?
Once a child is diagnosed with hypertension, its cause must be determined. The two major types of hypertension are as follows:
Essential hypertension (i.e., without any identifiable cause) occurs in 50% to 60% of children with hypertension. The majority of these children will be obese.
Secondary hypertensionThe common causes of secondary hypertension include renal (kidney) disease, cardiovascular (heart and vessel) disease, endocrine (hormone or metabolism) disorders, and other miscellaneous conditions.
How is secondary hypertension diagnosed?
A thorough history and physical examination is essential in evaluating a child with secondary hypertension
In the history, the following significant points should be addressed:
Symptoms suggesting associated disease (e.g., unexplained fever – in kidney infection; leg pains with exercise – in coarctation of the aorta [see Coarctation of the Aorta article]; weight loss and tremor – in hyperthyroidism; sweating, night terrors, and palpations – in an adrenal gland tumor)
Medications or chemicals that can raise the blood pressure (e.g., birth control pill, steroids, amphetamines)
Any history of trauma
The physical examination should include the following:
Blood pressure and pulse should be taken in both the upper and the lower extremities. (A difference in pressure and pulse between the arms and the legs is diagnostic of coarctation of the aorta.)
A careful abdominal examination should be performed to detect masses (e.g., polycystic kidney disease, where the kidneys are too large because of multiple cysts; tumors) and abnormal pulses (e.g., renal artery stenosis, where the vessels supplying blood to the kidneys are abnormally narrow).
A careful examination of the skin should be performed (e.g., cafe-au-lait spots or brownish spots in neurofibromatosis, striae or skin stretch marks, hirsutism or male hair growth pattern of Cushing’s syndrome).
A thorough eye examination should be performed.
The only routine laboratory tests that should be performed are as follows: urine dipstick, blood electrolytes, blood urea nitrogen, and creatinine. Other laboratory tests should be ordered based on both the history and the physical examination.
How is childhood hypertension treated?
All children with significant, sustained hypertension should be treated. The treatment of hypertension is divided into two major categories: hypertensive crisis and chronic hypertension.
. Hypertensive crisis is defined as life-threatening hypertension that is associated with hypertensive encephalopathy (changes in the brain and neurologic function due to the increased blood pressure) and/or acute heart failure. The calcium-channel blockers amlodipine and nifedipine are very effective in treating hypertensive crisis. Other medications used include diazoxide, nitroprusside, and minoxidil. No matter what medication is used, once acute blood pressure reduction is achieved, other medicines need to be added to maintain long-term blood pressure control.
. Chronic hypertension The ideal therapy for chronic hypertension is to treat, if possible, the underlying disease that is responsible for the hypertension. If this is not possible, then nonpharmacologic (not using medications) and pharmacologic (using medications) intervention is needed.
Nonpharmacologic treatment Dietary management should be the initial form of therapy in all children with hypertension. Weight loss is the treatment of choice for the obese adolescent with essential hypertension. Lowering salt intake also can be helpful. In addition to dietary management, other nonpharmacologic therapies include quitting smoking, not taking oral contraceptive pills and other vasoactive drugs, and avoiding heavy alcohol consumption. Daily physical activity should be encouraged.
Pharmacologic treatment In pediatric patients, the first line of antihypertensive medications are angiotensin converting enzyme inhibitors and calcium channel blockers. The most common side effect of angiotensin converting enzyme inhibitors is a chronic cough. If a chronic cough requires the child to s taking the converting enzyme inhibitor, an alternate therapy is angiotensin receptor antagonists. The most common side effects of calcium channel blockers are a rapid heart rate and fluid retention.
Until recently, diuretics and beta-blockers were the most commonly used drugs to treat childhood hypertension. However, most pediatricians are now reluctant to use them because of evidence suggesting that these agents may adversely affect plasma lipids and insulin sensitivity. Beta-blockers also can cause depression and impair school performance.
Other antihypertensive agents used to treat refractory hypertension include centrally-acting drugs (e.g., Clonidine, Guanabenz), alpha-blockers, and vasodilators (e.g., hydralazine, minoxidil).
What is the goal of hypertension treatment?
The goal of therapy is to keep the child’s blood pressure below the 90th percentile for age and sex. Parents must be taught not only to monitor their child’s blood pressure at home, but also to monitor for signs of medication-induced side effects.
Successful therapy should not interfere with the child’s academic performance, involvement in sports, or interest in social activities. Participation in team sports should be encouraged unless there is clear evidence of heart dysfunction.
Once the child’s blood pressure is under good control, the child should be evaluated (at least) on an annual basis to assess cardiac status, physical growth and development, and sexual maturation patterns.
References
Report of the Second Task Force on Blood Pressure Control in Children. Pediatrics 1987;79(1):1-25.
Sinaiko AR. Pharmacologic management of childhood hypertension. Pediatr Clin North Am 1993;40(1):195-212.
Falkner B. Management of hypertensive children and adolescents. In: Izzo JL, Black HR, eds. Hypertension primer: the essentials of high blood pressure. 2nd ed. American Heart Association, 1999:424.
About the Author
Dr. Rocchini received both his bachelor of science degree in chemical engineering and his medical degree from the University of Pittsburgh. He completed his pediatric residency at the University of Minnesota and his pediatric cardiology fellowship at the Children’s Hospital of Boston. Dr. Rocchini is currently a professor of pediatrics and serves as director of pediatric cardiology at the University of Michigan. His research interests include interventional cardiac catheterization and obesity-induced hypertension.
Copyright 2012 Albert P. Rocchini, M.D., All Rights Reserved
Hypothyroidism
What is hypothyroidism?
What causes hypothyroidism?
Who gets hypothyroidism?
How does hypothyroidism cause disease?
What are the common findings?
How is hypothyroidism diagnosed?
How is hypothyroidism treated?
What are the complications?
How can hypothyroidism be prevented?
What research is being done?
Links to other information
Thomas P. Foley, Jr., M.D.
Professor of Pediatrics
School of Medicine
Professor of Epidemiology
Graduate School of Public Health
University of Pittsburgh
and
Children’s Hospital of Pittsburgh
Pittsburgh, PA
What is hypothyroidism?
Hypothyroidism is a deficiency in thyroid hormone secretion and a reduction of action of its hormones on the cells of the body. In children, there are two forms: (1) congenital hypothyroidism, present at birth; and (2) acquired hypothyroidism, a disease with an onset at any time after birth, usually after six months of age. In each of these two forms, there are two categories: (1) primary hypothyroidism, a failure of secretion by a damaged, defective, or absent thyroid gland; and (2) hypothalamic/pituitary hypothyroidism, a failure of the mechanism that stimulates the thyroid gland from the base of the brain, called the hypothalamus and the pituitary gland.
The thyroid hormones are called thyroxine, or T4, and triiodothyronine, or T3. The pituitary hormone that stimulates the thyroid gland is called thyroid stimulating hormone, or TSH.
What causes hypothyroidism?
In most cases, the cause of congenital hypothyroidism is not known. A few cases of inherited hypothyroidism are caused by mutations in the genes producing specific proteins (known as enzymes) that are required to make thyroid hormones. These mutations are inherited as autosomal recessive traits, i.e., the parents are unaffected, and the child is affected because the child receives a mutation from each parent. The parents have a one-in-four chance of having an affected child. Occasionally, a maternal disease or a medication can interfere with the thyroid gland of the unborn child. In certain areas of the world, a dietary lack of iodine causes hypothyroidism.
Most cases of acquired hypothyroidism are caused by autoimmune thyroiditis, a self-inflicted destruction of the thyroid by the body’s immune system. The processes that cause this condition are poorly understood. An inappropriate immune response is directed against the thyroid; the body does not recognize its own thyroid gland and generates an immune response against the normal thyroid cells to cause inflammation, irritation, or damage. Infrequently, surgical removal of the thyroid, certain medications or chemicals, or damage by radiation treatment for cancer may cause hypothyroidism.
Who gets hypothyroidism?
In most cases, congenital hypothyroidism is sporadic. It occurs worldwide, once in every 4,000 newborn infants, and affects girls twice as often as boys. In the inherited forms, an equal number of males and females are affected. An infant born to a mother with iodine deficiency, or an infant receiving, or exposed to a mother given, excessive amounts of iodine for antiseptic reasons may have hypothyroidism. The problem will continue until exposure to deficient or excessive iodine is corrected.
The majority of cases of acquired hypothyroidism occur in females with autoimmune diseases. It may occur: (1) as autoimmune thyroid disease only; (2) in association with other autoimmune diseases, such as insulin-dependent diabetes mellitus, alopecia (hair loss), rheumatoid arthritis, and lupus erythematous; or (3) in association with other diseases, such as Down syndrome and Turner’s syndrome.
How does hypothyroidism cause disease?
Thyroid hormones regulate metabolism, i.e., the amount of energy that is available for body functions. The production of proteins, especially those called enzymes, is controlled by thyroid hormones. They regulate how much sugar is converted to energy, how much protein is converted into muscle, and how much fat is stored and available for energy. From early in fetal life through two to three years of age, thyroid hormones acquired from the mother and those produced by the unborn child in the second and third trimesters of pregnancy are essential for normal brain development.
What are the common findings?
The common findings of hypothyroidism are summarized in the table. The appearance of a specific symptom and sign depends upon the age when hypothyroidism develops and its severity. Often, the findings in a child may not be obvious to the parents or the physician.
Table. Common findings of hypothyroidism.
Congenital hypothyroidism Acquired hypothyroidism
Findings during first two weeks of life – Prolonged yellow jaundice – Swelling of the eyelids, hands, and feet – Gestation more than 42 weeks – Birth weight more than 4 kg – Poor feeding – Low body temperature – An enlarged, swollen abdomen – Large midline fontanelles Findings beyond age one month – Darkening and mottling of the skin – Stressful, frequent, and labored breathing – Failure to gain weight; poor sucking ability – Decreased stool frequency – Decreased activity and lethargy Findings after age three months – Swollen and protuberant umbilicus – Infrequent and hard stools – Dry skin with yellow coloration – Large tongue – Generalized swelling – Hoarse cry Findings between six months and three years – Deceleration of linear growth – Coarse facial features – Dry skin with yellow coloration – Hoarse cry and large tongue – Swollen and protuberant umbilicus – Enlargement of the arm and leg muscles Findings during childhood – Slow growth and short stature – Delay in eruption of teeth and in shedding primary teeth – Muscle weakness; enlargement of the arm and leg muscles – Infrequent and hard stools – Dry skin with yellow coloration – Generalized swelling – Early sexual development Findings during adolescence – Late onset of puberty – Slow growth and short stature – Delay in eruption of teeth and in shedding primary teeth – Infrequent and hard stools – Dry skin with yellow coloration – Discharge from the breasts (in girls) – Generalized swelling
How is hypothyroidism diagnosed?
For newborns in many areas of the world, there are routine, mandated screening programs for congenital hypothyroidism. An elevated TSH on the newborn screening test requires that a repeat TSH test be performed. Other tests are performed to define the cause (inherited or sporadic) and the severity of hypothyroidism. In older infants and children, hypothyroidism is suspected by: (1) the presence of a large thyroid gland, or goiter, on examination of the neck; (2) a failure to maintain a normal rate of growth in height; (3) the symptoms and signs of hypothyroidism (see table); (4) a suspicion of it because members of the family have thyroid diseases; or (5) a routine screening for TSH in children at increased risk for hypothyroidism.
Hypothyroidism is diagnosed by blood tests for TSH and free T4. An elevated TSH is the most sensitive test for thyroid gland failure. A low free T4 is the diagnostic test for hypothalamic/pituitary hypothyroidism, and, usually, it is low in primary hypothyroidism, except in mild cases. Typically, the cause of thyroid gland failure is autoimmune thyroiditis, which is diagnosed by finding thyroid antibodies from a blood test. When the TSH value is increased and the T4 value is decreased, treatment with thyroxine is started. Thyroxine treatment usually is started when the TSH value is increased, yet the T4 value still is normal, as long as the cause of hypothyroidism is known.
In patients with hypothalamic/pituitary hypothyroidism, there usually are other pituitary hormone deficiencies, such as low levels of growth hormone (when the patient is subjected to growth hormone secretion tests); low levels of the sex hormones at the pubertal ages; and, less often, low levels of hydrocortisone and high levels of prolactin, which is the pituitary hormone that stimulates the secretion of milk in the mother after delivery.
How is hypothyroidism treated?
Treatment for hypothyroidism is easy and inexpensive. Typically, levothyroxine (L-thyroxine) is prescribed, and the tablets should be given at least 30 minutes before a meal or infant feeding. The daily dose per body weight steadily decreases from early infancy to childhood to an adult dose in adolescence. Treatment must be individualized; the amount that is absorbed and handled by the body differs among individuals. Careful monitoring of blood tests (TSH and free T4 or T4) until the values are normal, and then annually after three years of age once the tests become normal, is essential for optimal management.
What are the complications?
There are no complications from L-thyroxine treatment when the proper dose is taken and the blood tests are monitored on a regular basis. There are complications associated with unrecognized or inadequately treated hypothyroidism, and the worst outcome occurs if treatment is delayed in early infancy. Severe hypothyroidism before birth, and a delay of treatment after birth, is associated with an impaired intellect (as determined by IQ tests) and other neuropsychological abnormalities. After two or three years of age, there are adverse effects of untreated hypothyroidism; however, in most cases, they are reversible with adequate treatment.
Usually, if hypothyroidism is not adequately treated within approximately the first 6 to 12 months after its onset, a decrease in the rate of growth and, in many instances, shortness of stature occur. If prolonged into the adolescent years, the final adult height may be less than expected despite appropriate treatment. Prolonged hypothyroidism also is associated with high levels of cholesterol, slowing of mental function and school performance, an occasional episode of hip or knee pain from a slippage of the growth center of the hips (usually requires surgical intervention), and chronic constipation. Except for the normalization in growth, these abnormalities should disappear with appropriate treatment.
How can hypothyroidism be prevented?
Hypothyroidism cannot be prevented unless it is caused by a nutritional deficiency of iodine; excessive iodine intake; certain drugs, like lithium, that block the ability of the thyroid gland to produce thyroid hormones; or drugs that impair the absorption of thyroxine in those individuals who are taking it for hypothyroidism. If taken with thyroxine, iron medications and high fiber in food will prevent the absorption of thyroxine. Calcium tablets also may interfere with its absorption.
What research is being done?
In congenital hypothyroidism, research is being focused on the mutations that cause the familial thyroid disorders, the cause(s) of the sporadic disease, and the effects of maternal hypothyroidism on the unborn child. There is considerable interest in discovering the mechanisms that cause autoimmune diseases, with a focus on autoimmune thyroid diseases, the occurrence of diabetes mellitus in specific families with autoimmune thyroid diseases, and an understanding of those antibodies that injure thyroid cells and other antibodies that bind to and block the TSH receptor.
Links to other information
American Thyroid Association www.thyroid.org
Complete textbook available entitled “The Thyroid and Its Diseases” www.thyroidmanager.org
Lawson Wilkins Pediatric Endocrine Society www.lwpes.org
References
Familial Thyroid Diseases Including Hypothyroidism
Vassart G, Dumont JE, Refetoff S. Thyroid disorders. In: Scriver CR, Beaudet AL, Sly WS, Valle D, eds. The Metabolic and Molecular Bases of Inherited Disease. New York: McGraw-Hill, 1995:2883-2928.
Hypothyroidism
Fisher DA. Management of congenital hypothyroidism. J Clin Endocrinol Metab 1991;72:523.
Foley TP Jr. Congenital hypothyroidism. In: Braverman LE, Utiger RD, eds. Werner and Ingbar’s The Thyroid. 8th ed. Philadelphia: Lippincott-Raven, 2000:chap 82, part B, 977-983.
Foley TP Jr. Acquired hypothyroidism in infants, children and adolescents. In: Braverman LE, Utiger RD, eds. Werner and Ingbar’s The Thyroid. 8th ed. Philadelphia: Lippincott-Raven, 2000:chap 82, part C, 983-988.
Foley TP Jr. Hypothyroidism. In: Hoekelman RA, Friedman SB, Nelson NM, Seidel HM, Weitzman M, eds. Primary Pediatric Care. 4th ed. St. Louis: Mosby-Year Book, Inc., 2000:chap 218. In press.
LaFranchi S, Dussault JH, Fisher DA, Foley TP Jr, Mitchell ML. Newborn screening for congenital hypothyroidism: recommended guidelines. Pediatrics 1993;91:1203-1209.
About the Author
Thomas P. Foley, Jr. MD is Professor of Pediatrics in the School of Medicine and Professor of Epidemiology in the Graduate School of Public Health at the University of Pittsburgh and a member of the Medical Staff of the Children’s Hospital of Pittsburgh since 1971. Areas of scientific interest include (1) pediatric thyroidology with specific interests in congenital hypothyroidism, acquired hypothyroidism, hyperthyroidism and thyroid cancer; (2) auxology; and (3) international pediatrics with specific interests in radiation-induced thyroid cancer associated with the Chernobyl accident, autoimmune thyroid diseases, iodine deficiency disorders, newborn screening, toxicology and the effects of maternal hypothyroidism on fetal development. My personal interests are my family (wife, son and step-children), music (opera, classical music and traditional bluegrass music as lead vocal and guitar for The Allegheny River Boys, Revonah RS-506, 1978), sports (spectator and participant) and humanitarian assistance for children and child health through Child Health International (web site of a subsidiary: trfn.clpgh.org/orgs/bach).
Copyright 2012 Thomas P. Foley, Jr., M.D., All Rights Reserved
