Tinea capitis (ringworm of the scalp) is caused by dermatophytic fungi
Trichophyton tonsurans is the most common species in the US, and does NOT flouresce under Wood's lamp
Griseofulvin (20-25mg/kg/ day orally) is the standard first-line therapy in children older than 2 years, and has a good safety profile
Both tablet and suspension formulations are available, and it should be taken with food that are high in fat to increase drug concentrations
NO laboratory assessment of hepatic enzymes is required during the 8-week therapy course in children who have no history or clinical examination findings concerning for liver disease.
Topical antifungal agents are ineffective because they do not penetrate sufficiently into the hair shaft.
Non-accidental trauma (NAT) is most prevalent in children 0-3 months of age.
Radiographically classic metaphyseal lesions, rib fractures, and multiple fractures in various stages of healing are most commonly described in child abuse cases.
How do we know this is not just birth trauma from a shoulder dystocia, LGA (large for gestational age), or difficult vaginal delivery?
The key is dating the fracture. In this recent publication by Walters MM et al, prior to 8 days of life, 100% of radiographs did NOT have callus present. Callus formation is highly unlikely in fractures less than 9 days old, and typically appears by 15 days old. Callus thickness decreases inversely with fracture age. Additionally, subperiosteal new bone formation is highly unlikely in fractures less than 7 days old and typically appears by 10 days old. Subperiosteal new bone formation increases in thickness inversely with fracture age. Therefore, a clavicle fracture in a 7 day old without subperiosteal new bone formation or callus is unlikely from birth trauma and NAT should be considered.
How can you tell if subperiosteal new bone formation is present?
Subperiosteal new bone formation appears as a hazy cortical margin or a thin layer of bone separated from the original cortex by a discrete lucent interval. The new bone increases in thickness with time and may evolve to appear as a lamellated or multilayered linear hyperdensity parallel to the cortex of the bone. See referenced article for great picture examples.
See article for further pictures of subperiosteal new bone formation:
Walters MM, Forbes PW, Buonomo C, and Kleinman PK. Healing Patterns of Clavicular Birth Injuries as a guide to fracture dating in cases of possible infant abuse. Pediatric Radiology. October 2014; 44: 1224-1229.
Typical admission considerations for patients with bronchiolitis are work of breathing, hypoxia, and dehydration. The patients risk of apnea should also be considered. Younger infants with bronchiolitis are at a risk for apnea. Studies have cited anywhere from a 16-25% risk in younger infants. The problem lies in identifying those patients who are at risk and those who are not. This older study looked at 691 infants and developed criteria which identified all of the 2.7% of patients who developed apnea.
The high risk criteria used in this study were: 1) Full term and younger than 1 month; 2) Born < 37 weeks gestation and younger than 48 weeks post conception or 3) Parents already noted an episode of apnea with this illness.
Bottom line: Incorporate the infants risk of apnea into your disposition decision for patients with bronchiolitis.
Willwerth B, Harper M and Greenes D. Identifying Hospitalized Infants Who Have Bronchiolitis and Are at High Risk for Apnea. Annals of Emergency Medicine 48 (4) 2006.
