The Irritable Child

Stephen Ludwig, MDProfessor of Pediatrics and Emergency Medicine

Children’s Hospital of PhiladelphiaPerelman School of Medicine UPENN

NJAAP- Annual Conference 2016

DisclosureI have no relevant financial relationships

with manufacturers of any commercial products and/or provider of commercial

services discussed in this CME activity

I do not intend to discuss and unapproved/investigative use of commercial

products/devices in my presentation

Photographs have been taken by me with approval of the patients

Objectives

• Key in on irritability as an important patient/parent complaint

• Develop a differential diagnosis for this complaint

• Review some of the common entities that cause irritability

Case 1

• A 5 week old is brought to the ED for the problem of irritability. The child was full term product of vaginal delivery without complications. The child has periods of screaming that the parents cannot quiet. She draws her legs up and passes gas. She is growing and appears to be gaining weight. This happened the last three nights.

Case 1

• T 37 C P130 R 40 Wt. 4.2 K

• A well nourished, well developed baby with round cranium, open flat fontanel.

• HEENT – negative

• Chest – clear breath sounds

• Heart – regular rhythm no murmur strong pulses

• Abdomen – no organ increase, soft, non tender, normal bowel sounds

Case 1

• Neurological – normal

• Skin – no bruises, no rash

Are there any other parts of the exam you wish to check?

What is your diagnosis?

How will you instruct the parents?

Differential Diagnosis

• Colic

• Crying with Cause

– Skin –rash, hair tourniquet

– GU – torsion, hernia, UTI

– CNS – infection, anomaly

– Musculoskeletal – fracture

– HEENT- corneal abrasion, otitis, glaucoma

– Drugs - Electrolyte

Parental Instruction

• Colic

– Babies have to cry

– Avoid over-feeding

– Avoid over stimulation

– Saying “it will get better” does not help

Case 2

• A 12 month old child is brought in for 8 days of fever and irritability. The child has been seen by his pediatrician three times. The last visit two days ago resulted in the diagnosis of otitis media and the child started on Amoxicillin. There has been no improvement. The child is still febrile and irritable.

Case 2

• T 40.2 P 140 R 30 BP 120/68

• O2 Sat 97%

• Irritable child, Fontanel closed

• HEENT - conjunctivitis, red throat

• Neck - adenopathy on right

• Lungs - clear breath sounds

• Heart - tachycardia I/VI SEM

Case 2• Abdomen - tender over the liver

• GU - peeling diaper rash

• Extremities - warm and very well perfused

• Neurologic - irritable but normal mentation, strength and sensation

• What tests would you order?

• What diagnoses are you considering?

Tests to Order

• CBC

• ESR

• UA

• Liver Function

• EKG

• Chest X ray

• (ECHO)

Differential Diagnosis

• Kawasaki Disease

• Viral Illness - Adenovirus

• Streptococcal infection

• CNS Infection

• Drug Reaction

Kawasaki Syndrome

• First reported in 1967

• IVIG reported as effective in 1984

• Typical age 13-24 months

• 80% less than 5 years

• Youngest case reported at 2 weeks

Kawasaki Syndrome

• Fever for five days or more

• Presence of 4 of 5 criteria– Bilateral non purulent conjunctivitis

– Polymorphous rash

– Changes in lips and mucous membranes

– Changes in extremities

– Cervical lymphadenopathy

– (Irritability per Ludwig)

Case 3

• A two year old has been irritable and asking the mother to hold her. She has had fevers on and off. The parents noted that she did not want to walk today. They have seen a rash off and on that think is eczema. The child has been growing well and has normal development.

Case 3

• T 39.5 P 120 R 30 BP 110/70

• Uncomfortable child refusing to walk

• HEENT - negative

• Neck - supple

• Lungs - clear Heart - systolic ejection murmur

• Abdomen - enlarged liver and spleen

Case 3 • GU - normal

• Extremities - painful knee on right, foot appears normal, hip difficult to assess. Fifth finger with some in-curving

• Skin - dry skin, pale maculopapular rash

• Neurologic - irritable, unwilling to stand, sensation intact, motor seems strong, no ataxia

Case 3• What diagnoses are you considering?

• What laboratory tests would you order first?

• Are there procedures you would perform in the ED?

Juvenile Idiopathic Arthritis

• Heterogeneous group of illnesses – genetic and environmental causes 1:1000

• Several Forms – oligo articular-polyarticular – systemic- enthesitis

• Systemic -first 6-18 months spiking fever, irritability, rash

• May start with very subtle symptoms-check all joints

• Carditis, MAS, and other complications

Case 4

• A three year old is brought in for extreme irritability. The only thing the parents note is that she has had a cold recently with cough, rhinitis and low grade fever. They heard her crying in her bed and found her hysterical. They rushed her to the ED when they could not calm her.

Case 4

• Out of control child - screaming and thrashing about.

• As best as you can obtain T 37 C, P 150, R 30 BP 138/78 O2 Sat 70-97%

• Examination is difficult but there appear to be no localized findings.

• She continues to seem very frightened and out of control

Case 4• What is going on?

• How should you manage her behavior?

• Are there labs that will help you?

• Should you bring in the psychiatrist

Night Terrors

• “Temporary insanity”

• Look awake but not awake

• Abrupt onset from sleep

• Brought to ED

• Often follows a disruption in routine

• Return the child to sleep and they awake in their pre-morbid personality

Case 5

• A five month old is brought in for irritability. When parents came home from work they found the child crying and he has been crying ever since. If they leave him alone he settles down but if they try to pick him up and comfort him, he screams

Case 5

• Irritable child when touched - drifts off to sleep when left alone.

• T 37C P 180 R 22 BP 140/60 100% sat.

• HEENT - negative except serous fluid in ears. Neck is supple

• Chest - clear lung fields

• Heart - regular, tachycardia, no murmur

Case 5

• Abdomen - soft, non tender

• GU - normal

• Skin - bruise on L pinna

• Extremities - becomes very irritable when performing Kernig’s and Brudzinski’s. Falls asleep when left alone, cries when stimulated

Case 5

• What else is important to know in the history?

• What labs would you order and why?

• Anything else that might help you?

Non Accidental Trauma

• Child abuse

• Many different forms

• Very common

• Keep in mind for things that are hard to reconcile and understand

Case 6

• A three month old is referred from the pediatrician’s office for crying. The doctor reports that every time the child tries to nurse, he cries and refuses to drink. This has been happening off and on for awhile but today it is constant. Only past history is four episodes of wheezing

Case 6

• Well developed and well nourished child

• VS are normal

• Remainder of the PE is also normal except that you note intermittent posturing during your exam.

• The child can not sit alone and does not crawl.

Case 6

• What is your differential diagnosis list?

• Are there any labs you need?

• What would you do next?

• Should you admit this child?

Gastroesophageal Reflux GER

• Common but not always associated with pain and irritability

• Several modalities to use in making diagnosis

• Treatments also vary with severity of involvement

• Weight and response to acid blockers are good triage points

Case 7

• A one and one half year old has had irritability all day. Intermittently she screams out as if in pain. She has vomited once and has refused to eat or drink anything. She has no fever and no other symptoms.

• PMH, SH, FH are all negative.

Case 7

• T 38.2 P 140 R30 BP 90/60 96% Sat

• Wt. 12 K

• Irritable child intermittently, in between episodes of crying seems alert.

• Normocephalic

• HEENT - mild rhinorrhea

• Neck - supple

Case 7

• Lungs - clear

• Heart - regular and no murmurs

• Abdomen - scaphoid, decreased bowel sounds, no organ increase

• GU - negative

• Rectal - stool present no blood

• Skin - bruise like lesions on lower extremities

Case 7

• During your exam the child screams in pain and is inconsolable. She draws her legs up in flexion.

• What are you considering as to cause?

• What will you do next?

Intussusception• 3 months to 3 years but can be any age

• Primary – due to hypertrophy of Peyer’s patches in terminal ileum – ileo-ileal

• Secondary to Meckel’s, HSP. CF., Celiac

• Air enema predominant method of reduction

• U/S good diagnostic accuracy

• Irritability mixed with lethargy

Florin and Ludwig Netter Pediatrics 2011 Elsevier

Case 8

• A seven month old has been well – growing and developing normally. Suddenly today after her nap she started screaming and has been doing so all afternoon and into the evening. At times she has fallen asleep ( 4 or 5 times) only to awake and resume screaming

Case 8

• VS normal

• Well developed child who keeps her eyes closed and drifts off to sleep - when awake screams.

• HEENT - negative

• Chest - lungs clear Heart - regular tachycardia

Case 8

• Abdomen -negative

• GU - negative

• Extremities - normal

• Skin - normal - well perfused - no rash

• Neurologic - as described above

Case 8

• What is your next step?

• What are you considering?

• Are there tests to order?

Florin and Ludwig Netter Pediatrics 2011 Elsevier

Corneal Abrasion

• Topical anesthetic important

• Rule out ruptured globe

• Fluorescein papers

• If large and in visual axis refer to ophthalmologist

• Vertical abrasion – r/o FB

• Most heal within 24 hours.

• Irritability relieved by closing the eye

Summary

• The irritable child can pose diagnostic challenges

• Often details of the history are important such as acute or chronic, timing of onset of symptom, other physical finding

• What relieves the irritability is another good clue.