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40435699 Pediatrics in Review

40435699 Pediatrics in Review

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Cover credits:The artwork on the cover of this month's issue is by one of thewinners of our 2007 Cover Art Contest, 10-year-old Guillermo Sicard of NorthCanton, Ohio. Guillermo's pediatrician is Jennifer Kungle, MD.
Vol. 29, No. 6; June, 2008
 
Answer Key:
1. D; 2. B; 3. E; 4. B; 5. C
Articles
 Vomiting in Children:
Reassurance, Red Flag, or Referral?
183
Latha Chandran, Maribeth Chitkara
Complementary, Holistic, and IntegrativeMedicine:
Therapies for Acute Otitis Media
193
Cecilia Bukutu, Janjeevan Deol, Sunita Vohra
Index of Suspicion
201
David M. Barrett, Christine S. Cho, Nicolas Brown, Su-Ting T. Li,Selvi Senthilnathan, Todd M. Poret, Jodi K. Wenger
In Brief 
Thumb and Finger Sucking
207
Bacterial Vaginosis
209
Meconium Aspiration
212
Emetics, Cathartics, and Gastric Lavage
214
Internet-Only Article
Abstract appears on page 200.
The Difficult Pediatric Encounter:
Insights and Strategies for the Pediatric Practitioner
e35
 Andrea Gottsegen Asnes, Ambika Shenoy 
Cover: The artwork on the cover of this month’s issue isby one of the winners of our 2007 Cover Art Contest,10-year-old Guillermo Sicard of North Canton, Ohio.Guillermo’s pediatrician is Jennifer Kungle, MD.
contents
PediatricsinReview
 Vol.29No.6June2008
Editor-in-Chief:
Lawrence F. Nazarian,
Rochester, NY 
 Associate Editors:
Tina L. Cheng,
Baltimore, MD 
Joseph A. Zenel,
Portland, OR 
Editor, In Brief:
Henry M. Adam,
Bronx, NY 
Consulting Editor:
Janet Serwint,
Baltimore, MD 
Consulting Editor Online and MultimediaProjects:
Laura Ibsen,
Portland, OR 
Editor Emeritus and Founding Editor:
Robert J. Haggerty,
Canandaigua, NY 
Managing Editor:
Luann Zanzola
Medical Copy Editor:
Deborah K. Kuhlman
Editorial Assistant:
Sydney Sutherland
Editorial Office:
Department of PediatricsUniversity of RochesterSchool of Medicine & Dentistry 601 Elmwood Avenue, Box 777Rochester, NY 14642sydney_sutherland@urmc.rochester.edu
Editorial Board
Margie Andreae,
Ann Arbor, MI 
Richard Antaya,
New Haven, CT 
Laurence A. Boxer,
Ann Arbor, MI 
Latha Chandran,
Stony Brook, NY 
Joseph Croffie,
Indianapolis, IN 
Howard Eigen,
Indianapolis, IN 
Leonard Feld,
Charlotte, NC 
Jeremy N. Friedman,
Toronto, ON 
 Vincent A. Fulginiti,
Tucson, AZ 
Mark Goldstein,
Boston, MA 
Lindsey Grossman,
Baltimore, MD 
Russell J. Hopp,
Omaha, NE 
Hal B. Jenson,
Springfield, MA 
Chris P. Johnson,
San Antonio, TX 
J. Jeffrey Malatack,
Narberth, PA 
Blaise Nemeth,
Madison, WI 
John Pascoe,
Dayton, OH 
DeWayne Pursley,
Boston, MA 
Thomas T. Sato,
Milwaukee, WI 
Bennett A. Shaywitz,
New Haven, CT 
Michael Silberbach,
Portland, OR 
Nancy Spector,
Philadelphia, PA 
Surendra K. Varma,
Lubbock, TX 
Maximilian Zach,
Graz, Austria 
Publisher:
American Academy of PediatricsMichael J. Held, Director, Division of Scholarly Journals and ProfessionalPeriodicals
Pediatrics in Review
Pediatrics in Review
(ISSN 0191-9601) is owned and controlled by the American Academy of Pediatrics. It is published monthly by the American Academy of Pediatrics, 141Northwest Point Blvd., Elk Grove Village, IL 60007-1098Statements and opinions expressed in
Pediatrics in Review 
are those of theauthors and not necessarily those of the American Academy of Pediatrics or itsCommittees. Recommendations included in this publication do not indicate anexclusive course of treatment or serve as a standard of medical care.Subscription price for 2008 for print and online/online only: AAP Fellow $163/$124; AAP Candidate Fellow $153/$114; Nonmember $204/$159; Allied Health or Resident $152/$103. Institutions call for pricing (866-843-2271). For overseas delivery, add $95. Current single issue price is $10domestic, $12 international. Replacement issues must be claimed within 6months from the date of issue and are limited to three per calendar year.Periodicals postage paid at ARLINGTON HEIGHTS, ILLINOIS and atadditional mailing offices.© AMERICAN ACADEMY OF PEDIATRICS, 2008. All rights reserved.Printed in USA. No part may be duplicated or reproduced without permissionof the American Academy of Pediatrics.POSTMASTER: Send address changes to PEDIATRICS IN REVIEW 
, American Academy of Pediatrics Customer Service Center, 141 NorthwestPoint Blvd., Elk Grove Village, IL 60007-1098.
Pediatrics in Review Editorial Board Disclosures
The American Academy of Pediatrics (AAP) Policy on Disclosure of FinancialRelationships and Resolution of Conflicts of Interest for AAP CME Activities isdesigned to ensure quality, objective, balanced, and scientifically rigorous AAPCME activities by identifying and resolving all potential conflicts of interest beforethe confirmation of service of those in a position to influence and/or control CMEcontent.Every individual in a position to influence and/or control the content of AAPCME activities is required to disclose to the AAP, and subsequently to learners whether the individual has relevant financial relationships with manufacturers of commercial products and/or services discussed in the CME activities.Each of the editorial board members disclosed that the CME content he/sheedits/writes may include discussion/reference to generic pharmaceuticals, off-labelpharmaceutical use, investigational therapies, brand names, and manufacturers, if applicable.None of the editors had any relevant financial relationships to disclose, unless notedbelow. The AAP has taken steps to resolve any potential conflicts of interest:
Disclosures
Richard Antaya, MD, FAAP, disclosed that he participates in the Astellas Pharma,US, Inc., speaker bureau, advisory board, and clinical trials, and in the Novartisspeaker bureau.
Laurence Boxer, MD, FAAP, disclosed that he owns Amgen stocks.
Joseph Croffie, MD, MPH, FAAP, disclosed that he has research grants fromSucampo Pharmaceuticals (Lubiprostone), Medtronics (Bravo pH Capsule), andTAP pharmaceuticals (Prevacid), that he is on a Medtronics Advisory Board, andthat he serves on a speaker bureau for TAP.
Howard Eigen, MD, FAAP disclosed that he serves on speaker bureaus of AstraZeneca, Merck, GlaxoSmithKline, and TEVA, and that he is a consultant forTEVA and Astra Zeneca.
Leonard Feld, MD, MMM, PhD, FAAP, disclosed that he is a speaker for andcommittee member of a Pediatric Board Review Course (sponsored by AbbottNutrition) through the AAP New York Chapter.
Jeremy N. Friedman, MD, CHB, FAAP, disclosed that he serves on the Medical Advisory Board of the Proctor & Gamble Pampers Parenting Institute.
Lindsey K. Grossman, MD, FAAP, disclosed that she is a consultant for IntegraCase Management.
Russell J. Hopp, DO, FAAP, disclosed that he serves on speaker bureaus of  Astra-Zeneca, GlaxoSmithKline, Schering-Plough, and Sanofi-Aventis.
Hal B. Jenson, MD, MBA, FAAP, disclosed that he is a speaker and vaccineadvisory board member for Merck Vaccines as well as a speaker for SanofiPasteur.
J. Jeffrey Malatack, MD, FAAP, disclosed that he is a member of the AmericanBoard of Pediatrics.
Bennett A. Shaywitz, MD, FAAP, disclosed that he is a speaker/consultant forEli Lilly Co.
David L. Skaggs, MD, FAAP, disclosed that he is a consultant, speaker, andresearch grant recipient of Medtronics, Stryker Spine.
Surendra Varma, MD, FAAP, disclosed that he is on McKesson’s Professional Advisory Board for Texas Medicaid and on the speaker bureau of Pfizer Corp.
The printing and production of 
Pediatrics in Review 
ismade possible, in part, by an educational grant from Abbott Nutrition.
 
 Vomiting in Children:
Reassurance, Red Flag, or Referral?
Latha Chandran, MD,MPH,* Maribeth Chitkara,MD
Author DisclosureDrs Chandran andChitkara havedisclosed no financialrelationships relevantto this article. Thiscommentary doescontain a discussionof an unapproved/investigative use of acommercial product/device.
Objectives
After completing this article, readers should be able to:1. Discuss the most common causes of vomiting in children of different age groups.2. Understand the physiology behind the process of vomiting.3. Recognize common causes of vomiting based on the pattern and nature of emesis.4. Be familiar with the basic diagnostic evaluation and treatment strategies for differentcauses of vomiting.
Case Study
 A 1-month-old boy who has had postprandial vomiting for 1 week is admitted from the emergency department. He was born at term with no complications and had regained his birthweight by the second week after birth, feeding on a milk protein formula. He has been vomiting curdled milk intermittently for the past week, and on the day of admission was noted by his pediatrician to have lost 4 oz in weight since his last check-up.On physical examination, the infant is slightly lethargic and has a sunken fontanelle. The rest of his physical examination findings, including evaluation of his abdomen, are normal. Abdominal ultrasonography shows normal width and length of the pylorus. However, no food movement past the pylorus is observed. An echogenic density in the prepyloric area is noted. An upper gastrointestinal (GI) radiographic series and endoscopy reveal an antral web, which is excised surgically.
Physiology of Vomiting
 Vomiting involves the forceful expulsion of the contents of the stomach and is a highly coordinated, reflexive process. It is a feature of many acute and chronic disorders,including those causing increased intracranial pressure, metabolic diseases, and anatomicand mucosal GI abnormalities. Descent of the diaphragm and constriction of the abdom-inal musculature on relaxation of the gastric cardia force gastric contents back up theesophagus. The process is coordinated by the “vomiting center” in the central nervoussystem. The vomiting center receives sensory input from the vestibular nucleus (cranialnerve VIII), the GI tract via vagal afferents (cranial nerve X), and the bloodstream via thearea postrema, also known as the chemoreceptor (or chemoreceptive) trigger zone. Thestereotypicbehaviorsassociatedwithemesisarearesultofoutputfromthevomitingcenterthrough vagal, phrenic, and sympathetic nerves.
Types of Vomiting
 Vomiting can be classified according to its nature and cause as well as by the character of the vomitus. The nature of the vomiting may be projectile or nonprojectile. Projectile vomiting refers to forceful vomiting and may indicate increased intracranial pressure,especially if it occurs early in the morning. Projectile vomiting also is a classic feature of pyloric stenosis. Nonprojectile vomiting is seen more commonly in gastroesophagealreflux.Thesesomewhatarbitrarydescriptionsarenotdefinitiveinestablishingadiagnosis.Emesis often is classified based on its quality. The vomitus may be bilious, bloody, ornonbloodyandnonbilious.Emesisoriginatingfromthestomachusuallyischaracterizedasbeingclearoryellowandoftencontainsremnantsofpreviouslyingestedfood.Emesisthat
*Editorial Board.
Assistant Professor of Pediatrics and Emergency Medicine, Pediatric Hospitalist, State University of New York at Stony Brook,Stony Brook, NY.
Article
gastrointestinal
Pediatrics in Review
 
Vol.29 No.6 June 2008
183

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