Page 1043 - TNFlipTest

Toronto Notes 2019 Common Complaints
Caries
• milkcaries:decayofsuperiorfrontteethandbackmolarsinfirst4yroflife
• etiology:oftenduetoprolongedfeeding(e.g.puttobedwithbottle,prolongedbreastfeeding) • prevention
■ no bottle at bedtime, clean teeth after last feed
■ minimize juice and sweetened pacifier
■ clean teeth with soft damp cloth or toothbrush and water ■ water fluoridation
Enuresis
Definition
• involuntaryurinaryincontinencebydayand/ornightinchild>5yr
General Approach
• shouldbeevaluatedifdysuria,changeincolour,odour,stream,secondaryordiurnal,changeingait, stool incontinence
Primary Nocturnal Enuresis
• clinicalpresentation:involuntarylossofurineatnight,bladdercontrolhasneverbeenattained • epidemiology:boys>girls;10%of6yrolds,3%of12yrolds,1%of18yrolds
• etiology:developmentaldisorderormaturationallaginbladdercontrolwhileasleep
• management
■ time and reassurance (~20% resolve spontaneously each yr)
■ behaviour modification (limiting fluids, voiding prior to sleep), bladder retention exercises,
scheduled toileting overnight has limited effectiveness
■ conditioning: “wet” alarm wakes child upon voiding (70% success rate)
■ medications (for children >7 yr, considered second line therapy, may be used for sleepovers/camp):
DDAVP oral tablets (similar success rate as “wet” alarm therapy but higher relapse rate), imipramine (Tofranil®) (rarely used, lethal if overdose, SE: cardiac toxicity, anticholinergic effects)
Secondary Enuresis
• clinicalpresentation:involuntarylossofurineatnight,developsafterchildhassustainedperiodof bladder control (>6 mo)
• etiology:inorganicregressionduetostressoranxiety(e.g.birthofsibling,significantloss,family discord, sexual abuse), secondary to organic disease (UTI, DM, DI, sleep apnea, neurogenic bladder, CP, seizures, pinworms)
• management: treat underlying cause
Diurnal Enuresis
• clinicalpresentation:daytimewetting(60-80%alsowetatnight)
• etiology:micturitiondeferral(holdingurineuntillastminute)duetopsychosocialstressor(e.g.shy),
structural anomalies (e.g. ectopic ureteral site, neurogenic bladder), UTI, constipation, CNS disorders,
DM
• management:treatunderlyingcause,behavioural(scheduledtoileting,doublevoiding,good
bowel program, sitting backwards on toilet, charting/incentive system, relaxation/biofeedback), pharmacotherapy
Encopresis
• clinicalpresentation:fecalincontinenceinachild>4yrold,atleastoncepermofor3mo
• prevalence:1-1.5%ofschool-agedchildren(rareinadolescence);M:F=6:1inschool-agedchildren
• causes:chronicconstipation(retentiveencopresis),Hirschsprungdisease,hypothyroidism,
hypercalcemia, spinal cord lesions, anorectal malformations, bowel obstruction
Retentive Encopresis
• definition:childholdsbowelmovement,developsconstipation,leadingtofecalimpactionandseepage of soft or liquid stool (overflow incontinence)
• etiology
■ physical: painful stooling often secondary to constipation
■ emotional: disturbed parent-child relationship, coercive toilet training, social stressors
• clinicalpresentation ■ history
◆ crosses legs or stands on toes to resist urge to defecate ◆ distressed by symptoms, soiling of clothes
◆ toilet training coercive or lacking in motivation
◆ may show oppositional behaviour
◆ abdominal pain ■ physical exam
◆ digital rectal exam or abdo x-ray: large fecal mass in rectal vault
◆ anal fissures (result from passage of hard stools) ■ palpable stool in LLQ
Pediatrics P9
Treatment for primary nocturnal enuresis should not be considered until 7 yr of age due to high rate of spontaneous cure
Antidiuretic Hormone Regulation in Primary Nocturnal Enuresis
Arch Dis Child 1995;73(6):508-11
Purpose: To evaluate the efficacy of DDAVP for the treatment of primary nocturnal enuresis.
Methods: Children with primary nocturnal enuresis were compared with a corresponding control group. Diurnal and nocturnal urine production, ADH secretion, and plasma osmolality were determined. Results: Ten children (mean age 10.5 yr) with primary nocturnal enuresis were compared to a control group of eight patients. No differences in urine production, ADH levels during day and night, or plasma osmolality were found. However, the enuretic children required a markedly greater ADH output (2.87 pg/ml/mmol/kg vs. 0.56 in controls; p<0.01).
Conclusion: ADH secretion is a function of plasma osmolality. Urine production is not increased at night in individuals with primary nocturnal enuresis because of lower ADH secretion.