M2E Too! Mellick's Multimedia EduBlog
The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Wednesday, March 1, 2017

Oldie but Goodie Pediatric Clinical Concepts

​A number of older clinical concepts may be unfamiliar to younger clinicians, but these clinical concepts are useful in pediatric medicine. Some of these concepts showed up in the medical literature for the first time nearly a century ago. Physicians should feel free to question the potential value and validity of older clinical concepts that aren't at the forefront of medical education, but my experience of more than 30 years practicing pediatrics and emergency medicine has repeatedly affirmed to me that these are valuable in emergency medicine.​

Parenteral Diarrhea

The concept of parenteral diarrhea has been around for at least a century. (Can Med Assoc J 1922;12[8]:554; Proc R Soc Med 1944;37[9]:479; Pediatrics 1948;2[5]:525.) It is often not recognized, acknowledged, or discussed as an important clinical entity, however. This type of diarrhea is caused by infections outside the gastrointestinal tract. The pathophysiology is unclear, but infections elsewhere in the body such as otitis media or (more frequently) urinary tract infections are often associated with diarrhea.

The diarrhea, however, can be characterized as different from the diarrhea patterns commonly seen with gastrointestinal diseases. Parenteral diarrhea is typically only two or three loose stools a day rather than the five to 10 watery stools seen with most cases of acute gastroenteritis. Parenteral diarrhea can also occur in concordance with occasional vomiting and fever. I have seen this pattern so many times that I immediately begin looking for other etiologies when parents describe only two or three episodes of diarrhea a day.

Unfortunately, this diarrhea presentation is frequently labeled as viral gastroenteritis, and associated infections are not sought. My experience is that urinary tract infections are the most common infection presenting as parenteral diarrhea. Of concern is that 60 percent of febrile urinary tract infections in children are upper tract disease or pyelonephritis. I am confident that thousands of pediatric urinary tract infections have been missed because the associated parenteral diarrhea served as a red herring that befuddled the clinician. My investigations have been rewarded scores of times when following this clinical clue. Parenteral diarrhea is admittedly not at the forefront of clinical teaching, but it is found in current editions of reputable pediatric textbooks such as Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine.​

Conjunctivitis-Otitis Syndrome

Another clinical concept that doesn't seem to get a lot of respect is the conjunctivitis-otitis syndrome. The association of otitis media and conjunctivitis has been described since the early 1980s. (Pediatrics 1948;2[5]:525.)

What is unique is the temporal association of the two infections. The infectious agent is most commonly nontypable strains of Haemophilus influenza. (Pediatrics 1982;69[6]:695; Pediatrics. 1985;76[1]:26.) The role of sinusitis in this association is suspected, but doesn't seem to be widely discussed. My experience is that the conjunctivitis-otitis syndrome can often be diagnosed from across the room. These children will have impressive amounts of purulent drainage from their reddened eyes and ears. The amount of drainage and crusting around the eyes is consistently more dramatic than that seen with typical viral infection. A history that sounds like sinusitis with nasal drainage longer than 10 days is often associated in my clinical experience. Polymyxin B/trimethoprim provides reasonable coverage against the ocular pathogens, and amoxicillin/clavulanate should be used for the sinusitis.​


Double Sickening

Double sickening is currently seen mostly in patients with sinusitis. Historically, it is seen in a clinical setting where the patient is apparently improving or stable and then suddenly worsens. Sinusitis commonly presents with double sickening, but bacterial pneumonia also presents with this clinical pattern. (Clin Infect Dis 2012;54[8]:e72.)

These patients typically have three to four days of an upper respiratory tract infection and appear to be improving. Then they suddenly have a fever, and the patients appear and feel sicker. The bottom line is that double sickening is a valuable clue that should prod the clinician to dig a little deeper looking for sinusitis or to order imaging searching for evidence of pneumonia.

High-quality randomized controlled trials are practically nonexistent for important clinical concepts with only older observational studies available. Nevertheless, these older clinical concepts have withstood the test of time, have validated themselves clinically, and deserve respect.

This video shows another oldie but goodie tip for how to position a child properly for ear cleaning.​


Listen in as Dr. Mellick talks with a mother about her daughter's double sickening.​

mellick double sick.jpg