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american academy of pediatrics COMPREHENSIVE NEONATOLOGY REVIEW AND ONLINE JOURNAL
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DECEMBER 2015Vol. 36 No. 12
www.pedsinreview.org
Meningitis
Swanson
Pain and Symptom
Management in
Pediatric Palliative Care
Komatz, Carter
Substance Abuse,
General Principles
Nackers, Kokotailo, Levy
ONLINE
Visual Diagnosis:
A 2-month-old Boy
With an Unusual Rash
Benza, Stankovic
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COMPREHENSIVE NEONATOLOGY
REVIEW AND ONLINE JOURNAL
• Peer-reviewed Articles •/WNVKOGFKC6GCEJKPI(GCVWTGU
• NICU-team Case Studies • 24/7 Online Access
• Clinical Reviews • CE/CME Credit
Subscribe today at shop.aap.org/2015-NeoReviewsPlus
Supported, in part, through an educational
grant from Abbott Nutrition, a division of
Abbott Laboratories, Inc.
The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
This activity has been approved for AMA PRA Category 1 Credit ™.
,contents
Pediatrics in Review ®
Vol. 36 No. 12 December 2015
Editor-in-Chief: Joseph A. Zenel, Sioux Falls, SD
Deputy Editor: Hugh D. Allen, Houston, TX
Associate Editor: Philip R. Fischer, Rochester, MN
ARTICLES Associate Editor, Index of Suspicion: Deepak M. Kamat,
Detroit, MI
514 Meningitis Associate Editor, In Brief: Henry M. Adam, Bronx, NY
Douglas Swanson Associate Editor, In Brief: Janet Serwint, Baltimore, MD
Associate Editor, CME: Paula Algranati, Longmeadow, MA
527 Pain and Symptom Management in Pediatric Editorial Fellow: Mark F. Weems, Memphis, TN
Editor Emeritus: Lawrence F. Nazarian, Rochester, NY
Palliative Care Founding Editor: Robert J. Haggerty, Canandaigua, NY
Managing Editor: Luann Zanzola
Kelly Komatz, Brian Carter Editorial Associate: Sara Strand
Medical Copyediting: Deborah K. Kuhlman
535 Substance Abuse, General Principles
Kirstin A. M. Nackers, Patricia Kokotailo, Sharon J. L. Levy EDITORIAL BOARD
Robert D. Baker, Buffalo, NY
INDEX OF SUSPICION Peter F. Belamarich, Bronx, NY
Theresa Auld Bingemann, Rochester, NY
545 Case 1: Clavicular Pain of 2 Months’ Duration Stephen E. Dolgin, New Hyde Park, NY
in a 9-year-old Girl Lynn Garfunkel, Rochester, NY
Rani Gereige, Miami, FL
Rebecca C. Brady, Alvin H. Crawford Joseph Gigante, Nashville, TN
Nupur Gupta, Boston, MA
548 Case 2: Recurrent Anemia in a 10-year-old Girl Gregory A. Hale, St. Petersburg, FL
Uzma Rani, Aamer Imdad, Mirza Beg Thomas C. Havranek, Bronx, NY
Jacob Hen, Bridgeport, CT
551 Case 3: Abnormal Eye Movements and Jeffrey D. Hord, Akron, OH
Neal S. LeLeiko, Providence, RI
Congestion in a 3-month-old Boy Michael Macknin, Cleveland, OH
Joanna Wigfield, Aadil Kakajiwala, Michael L. Forbes, Susan Massengill, Charlotte, NC
Jennifer L. Miller, Gainesville, FL
Prasad Bodas Carrie A. Phillipi, Portland, OR
Peter Pizzutillo, Philadelphia, PA
553 Correction Mobeen Rathore, Jacksonville, FL
Jennifer S. Read, Rockville, MD
IN BRIEF E. Steve Roach, Columbus, OH
554 Upper Respiratory Tract Infections Sarah E. Shea, Halifax, Nova Scotia
Andrew Sirotnak, Denver, CO
Benjamin Weintraub Miriam Weinstein, Toronto, ON
557 Statement of Ownership PUBLISHER: American Academy of Pediatrics
Mark Grimes, Director, Department of Publishing
ONLINE Joseph Puskarz, Director, Division of Journal Publishing
e43 Visual Diagnosis: A 2-month-old Boy With an Pediatrics in Review offers 36 CME articles per year. A maximum
of one AMA PRA Category 1 Credit TM is earned after achieving a
Unusual Rash 60% score on each designated quiz.
Natalia Benza, Curt Stankovic CME STATEMENTS:
The American Academy of Pediatrics (AAP) is accredited by
the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for
physicians.
The AAP designates this journal-based CME activity for a
maximum of 1.00 AMA PRA Category 1 Credit TM. Physicians
should claim only the credit commensurate with the extent
of their participation in the activity.
Pediatrics in Review® (ISSN 0191-9601) is owned and controlled by the American Academy of Pediatrics. This activity is acceptable for a maximum of 1.00 AAP credit.
It is published monthly by the American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098. These credits can be applied toward the AAP CME/CPD*
Statements and opinions expressed in Pediatrics in Review® are those of the authors and not necessarily those of the American Award available to Fellows and Candidate Members of the
Academy of Pediatrics or its Committees. Recommendations included in this publication do not indicate an exclusive course of AAP.
treatment or serve as a standard of medical care.
Subscription price for 2015 for print and online/online only: AAP/CPS Member $199/$152; AAP National Affiliate Member $157/$107; The American Academy of Physician Assistants accepts
Nonmember $249/$193; Allied Health or In-training $185/$125. Institutions call for pricing (866-843-2271). For overseas delivery, add $120. certificates of participation for educational activities certified
Current single issue price is $10 domestic, $12 international. Replacement issues must be claimed within 6 months from the date of issue for AMA PRA Category 1 Credit TM from organizations accredited
and are limited to three per calendar year. Periodicals postage paid at ARLINGTON HEIGHTS, ILLINOIS and at additional mailing offices. by ACCME. Physician assistants may receive a maximum of 1.00
© AMERICAN ACADEMY OF PEDIATRICS, 2015. hour of Category 1 credit for completing this program.
All rights reserved. This program is accredited for 1.00 NAPNAP CE contact
Printed in USA. No part may be duplicated or reproduced without permission of the American Academy of Pediatrics. hour; pharmacology (Rx) and psychopharmacology contact
POSTMASTER: Send address changes to PEDIATRICS IN REVIEW®, American Academy of Pediatrics Customer Service Center, 141 hours to be determined per the National Association of
Northwest Point Blvd., Elk Grove Village, IL 60007-1098. Pediatric Nurse Practitioners (NAPNAP) Continuing Education
Pediatrics in Review® Print Issue Editorial Board Disclosures Guidelines.
The American Academy of Pediatrics (AAP) Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for
AAP CME Activities is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying It has been established that each CME activity will take the
and resolving all potential conflicts of interest before the confirmation of service of those in a position to influence and/or control learner approximately 1 hour to complete.
CME content. All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the *Continuing Professional Development
AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with
the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in CME activities. Commercial How to complete this activity:
interest is defined as any entity producing, marketing, reselling or distributing health-care goods or services consumed by, or used Pediatrics in Review can be accessed and reviewed in print or
on, patients. online at http://pedsinreview.aappublications.org. Learners
Each of the editorial board members, reviewers, question writers, PREP Coordinating Committee members and staff has disclosed, if can claim credit monthly online upon completion of each CME
applicable, that the CME content he/she edits/writes/reviews may include discussion/reference to generic pharmaceuticals, off-label article. The deadline for completing this activity is December
pharmaceutical use, investigational therapies, brand names, and manufacturers. None of the editors, board members, reviewers, 31, 2017. Credit will be recorded in the year in which it is
question writers, PREP Coordinating Committee members, or staff has any relevant financial relationships to disclose, unless noted submitted. It is estimated that it will take approximately 1 hour
below. The AAP has taken steps to resolve any potential conflicts of interest. to complete each CME article. This activity is not considered
Disclosures to have been completed until the learner documents
• Paula Algranati, MD, FAAP, has disclosed that her family member is on the AstraZeneca speaker bureau. participation in that activity to the provider via online
• Lynn Garfunkel, MD, FAAP, disclosed that her family member is an employee of Philips Healthcare. submission of answers. Course evaluations are online.
• Nupur Gupta, MD, MPH, disclosed she receives royalties from Springer US as co-editor for MassGeneral Hospital
for Children Handbook of Pediatric Global Health.
• Miriam Weinstein, MD, has disclosed she is a paid consultant and advisory board member for Johnson & Johnson,
Pierre Fabre, PediaPharm, Tribute, and Valeant; she is a paid consultant for La Roch Posay (funding to attend and support
a hospital-run eczema teaching center); and receives honoraria for lectures from Galderma and Pediapharm.
The journal extends special thanks to the following question writers and reviewers who contributed to this issue:
–Joseph Gigante, MD
–Melissa Held, MD
–Sydney Rice, MD
Answer Key appears on page 556.
, Meningitis
Douglas Swanson, MD*
*University of Missouri, Kansas City; Division of Infectious Diseases, Children’s Mercy Hospitals and Clinics, Kansas City, MO.
Educational Gaps
1. The epidemiology of bacterial meningitis in children is changing.
2. Routine neuroimaging is not necessary for the initial medical
evaluation of children with suspected bacterial meningitis who do not
have clinical signs of brain herniation.
Objectives After completing this article, the reader should be able to:
1. Describe the causes, clinical manifestations, and general approach to
the diagnosis, treatment, and prevention of the different types of
meningitis in children of various ages.
2. Understand the indications for neuroimaging, adjunctive
corticosteroids, and repeat lumbar puncture in children with bacterial
meningitis.
3. Recognize the complications and sequelae of bacterial meningitis in
children.
INTRODUCTION
Bacterial meningitis is a severe, life-threatening infection of the central nervous
system that requires immediate medical attention. Even with appropriate treat-
ment, morbidity and mortality can be substantial. It is essential for clinicians to
recognize the clinical signs and symptoms of meningitis and understand its
management and prevention. The focus of this review is acute bacterial meningitis
in children, including its causes in different age groups, epidemiology, clinical
features, diagnosis, treatment, and sequelae.
ETIOLOGY AND EPIDEMIOLOGY
Acute Bacterial Meningitis
Acute bacterial meningitis has a relatively rapid onset of symptoms, and routine
laboratory techniques can usually identify the pathogen. The most common
causes have been Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus
influenzae type b (Hib), group B Streptococcus (GBS), and Listeria monocytogenes AUTHOR DISCLOSURE Dr Swanson has
disclosed that he has a research grant from
(Table 1). (1)(2)(3) These organisms caused more than 80% of acute bacterial
Pfizer. This commentary does not contain
meningitis in children during the 1970s and 1980s. In 1990, conjugate Hib a discussion of an unapproved/investigative
vaccine was introduced. It has almost eliminated Hib meningitis in countries use of a commercial product/device.
514 Pediatrics in Review
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