Brown Pediatrics

Brown's Pediatric Residency Blog

Category: Primary Care

This is… Lumbar Puncture

Case: Jane is a 2 week-old, previously healthy, ex- full term girl who presents to the ED from her PCPs office after being found to have a temperature of 102.5 rectally. On exam, she is fussy but consolable and has an otherwise normal exam.  In addition to blood and urine studies, you plan to perform a lumbar puncture. What would be other indications and even contraindications for an LP? What are the various techniques? Should you use local anesthesia?  


Lumbar Puncture: The basics


  • The most common indication for lumbar puncture is to diagnose meningitis (Bonadio, 2014)
    • Other indications include diagnosing: demyelinating diseases, subarachnoid hemorrhage, or idiopathic intracranial hypertension (formerly pseudotumor cerebri)


  • Suspected intracranial pressure elevation
  • Clinical/Physiological Instability (hypotension, respiratory distress, status epilepticus)
  • Coagulopathy
  • Infection of overlying skin


Basics of setup

After discussing the case with the team, you decide that Jane has no contraindications and that it is important to rule out meningitis.  What do you need, and how do you set up?

1.  Equipment

  • Most (if not all) of your equipment will be included in a commercially available tray (Figure 1 as an example).
    • In general, you will need the following
      • Spinal needle (1.5″ or 3″ depending on the patient)
      • sterile gloves and drapes
      • Povidone-Iodine scrub
      • Monometer tune (to measure CSF pressure)
      • Sterile tubes for CSF collection


Figure 1: LP Tray (Picture from Bonadio, 2014)


2. Position 

  • In the younger child, and in those you need to measure CSF pressures, the child should be placed in the lateral decubitus position
  • In older children, the seated position can also be used (Figure 2)
  • Remember, the spinal cord ends around L2. Therefore, the needle should enter the L3/4 or L4/5 disc space
    • The L3/4 disc space will be transected by the line that connects the iliac crests (as seen in Figure 2).


Figure 2: LP Landmarks (Picture from Bonadio, 2014)


Maximizing Success

As you are gathering your materials, you begin wondering what can be done to maximize the success of your procedure.

1.)  Anesthesia

  • Topical (“EMLA”) vs local (1% lidocaine infiltration)
    • Use of local anesthetic associated with an increased odds ratio (OR = 2.2) for success (Baxter, 2006)
    • Other RCTs (Pinheiro et al, 1993; Nigrovic, 2007) found that local infiltration did not increase success, but statistically decreased the amount of struggling in infants.
      • Note: Despite not finding any differences in success rates between the two methods, it is important to note that local infiltration did not lead to decreased success (concern for a loss of landmarks, etc).

2.) Early stylet removal (“Cincinnati” Method)

  • In this method, the stylet is removed after puncturing the epidermis
    • Baxter et al found a trend towards increased success in residents employing this method, but this was not statistically significant (Baxter, 2006)
    • Nigrovic et al did find an association between leaving the stylet in and with the composite outcome of traumatic or unsuccessful lumbar puncture (Nigrovic, 2007)

Conclusion: Use an anesthetic (topical or local infiltrate) and consider removing the stylet early


Now that we know what we need, where we need to go, and what helps maximize success, how do we do the procedure?


NEJM Tutorial

Another Example from EM:RAP


Faculty Reviewer: Jeff Riese, MD


  • Baxter AL et al. “Local Anesthetic and Stylet Styles: Factors Associated with Resident Lumbar Puncture Success.” Pediatrics. 2006;117(3)876-881
  • Bonadio W. “Pediatric Lumbar Puncture and Cerebrospinal Fluid Analysis.” The Journal of Emergency Medicine. 2014;46(1)141-150.
  • Nigrovic et al. “Risk Factors for Traumatic or Unsuccessful Lumbar Punctures in Children.” Annals of Emergency Medicine. 2007;49(6)762-771
  • Pinheiro JM et al. “Role of Local Anesthesia During Lumbar Puncture in Neonates” Pediatrics. 1993;91(2)379-82


Too Much Pressure

Image Credit: Pixabay



Case: Andrew is a 16yo post-pubertal male without any past medical history who comes to clinic for his annual well-child check. His vitals at triage showed a blood pressure of 142/92. You note that he was seen in urgent care twice in the last 2 months with a similarly high blood pressures. His BMI is >95th percentile. How should you address his blood pressure today? Specifically, what further workup and/or treatment should be undertaken?



How is high blood pressure classified? (based on The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents)

  • Hypertension is defined as an average systolic blood pressure (SBP) and/or diastolic BP (DBP) that is ≥95th percentile for gender, age, and height on 3 occasions.
    • These 3 occasions needs to be separated by days-weeks
    • Note: Measures obtained by oscillometric devices (aka automatic BP machines) that exceed the 90th percentile should be repeated by auscultation.
  • Prehypertension in children is defined as average SBP or DBP levels that are ≥90th percentile but <95th percentile.
    • As with adults, adolescents with BP levels >120/80 mmHg should be considered prehypertensive.
  • A patient with BP levels ≥95th percentile in a physician’s office or clinic, who is normotensive outside a clinical setting, has “white-coat hypertension.”
    • Ambulatory BP monitoring (ABPM) is usually required to make this diagnosis.

Image Credit: Pixabay




  • The prevalence of primary and secondary hypertension is 4.5% and 13%, respectively (Gupta-Malhotra et al, 2015)
    • Given low screening rates, true prevalence may be higher
  • Children with essential (primary) hypertension tend to be older (>6), have a family history of hypertension (Gupta-Malhotra et al, 2015)
    • Conversely, infants and preschool-aged children with elevated blood pressure are more likely to have a secondary form of hypertension.


Etiology & Workup

  • While secondary causes of hypertension are more common in children than adults, children can also have primary hypertension (see Table below


<1yr old (%) 1-5 years (%) 6-12 years (%) 13-19years (%)
Respiratory (61) Respiratory (29) Essential (57) Essential (49)
Renal (13) Renal (27) Renal (27) Renal (20)
Medication Related (9) Essential (19) Neurological (7) Medication Related (11)

Table 1: Most common causes of hypertension by age (adapted from Gupta-Malhotra et al, 2015)

  • Workup for secondary causes should be individualized
    • Children with BPs ≥95th percentile (stage 1 hypertension) should have the following (NHBPEP, 2004; Ingelfinger JR, 2014):
      • Targeted History and Physical to elicit risk factors including: relevant past medical history, family history, medications and other exposures (e.g. stimulants, etc), and physical exam.
        • Retinal Exam also indicated for children with ≥Stage 1 HTN
      • Lab Studies: basic metabolic panel, complete blood count, urinalysis & culture
        • Other lab studies could include (if clinically indicated): fasting lipid panel and glucose, plasma renin, plasma and urine steroid levels, and/or plasma and urine catecholamines
      • Imaging: Renal ultrasound and echo



  • For children with pre-hypertension and Stage 1 hypertension, lifestyle changes are recommended first line (Ingelfinger JR, 2014).
    • Examples include: dynamic exercise, DASH diet (Couch SC et al, 2008)

Image Credit: Pixabay



  • For children who continue to be hypertensive despite lifestyle interventions, evidence of end organ damage, or evidence of secondary etiologies pharmacologic intervention may be required
    • No consensus exists for “optimal” first line agent
      • Acceptable regimens include: ACE inhibitors, calcium channel blockers, or diuretics (Dhull RS et al, 2016).


Back to the Case: Upon seeing Andrew, you repeat his blood pressure manually, which is also high. He has no other “red flags” on history or exam. Given his age and comorbidities (obesity), Andrew most likely has essential hypertension (3 readings >140/90). Initial workup should include: basic labs (BMP, CBC, and UA) and imaging (renal ultrasound and ECHO). Provided these are all reassuring, he should first undergo lifestyle interventions, with medical management initiated if his BPs do not normalize.



  1. “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” Pediatrics Aug 2004, 114 (Supplement 2) 555-576
  2. Couch SC et al. “The Efficacy of a Clinic-based Behavioral Nutrition Intervention Emphasizing a DASH-type Diet for Adolescents with Elevated Blood Pressure.” J Pediatr. 2008;152(4)494-501
  3. Dhull RS et al. “Pharmacologic Treatment of Pediatric Hypertension.” Current Hypertension Reports. 2016;18:32
  4. Ingelfinger JR. “The Child or Adolescent with Elevated Blood Pressure.” NEJM. 2014;370:2316-2325
  5. Gupta-Malhotra M et al. “Essential Hypertension vs. Secondary Hypertension Among Children.” Am J Hypertens. 2015;28(1):73-80
  6. Sinaiko AR. “Hypertension in Children.” NEJM. 1996;335:1968-1973.
  7. Yang Q et al. “Trends in High Blood Pressure among United States Adolescents across Body Weight Category between 1988 and 2012.” JPeds. 2016;169:166-73.e3.

Image of the Week: 10/28

Case: Tommy is a 6yo boy coming in for a sick appointment. His mother states that he has had a limp for “a while.” He is an active kid and she thought he had bruised himself and didn’t think too much of it. Now, 2 weeks later, he has not improved.  After a complete history and physical, an x-ray of the hips is obtained: 




AP Hip


Frog leg view

Diagnosis: Legg-Calve-Perthes Disease

Radiology Findings (courtesy of Radiopaedia):  The left superior femoral epiphysis is markedly flattened, sclerotic and appear to be undergoing fragmentation. Alignment is unremarkable and the pelvis and acetabulum appear normal. The Right hip appears normal.

Brief Summary:

  • Legg-Cavle-Perthes Disease is an idiopathic avascular necrosis of the femoral head
  • Generally affects children between 2-12 years of age and tends to be more common in boys as opposed to girls  (Hermann et al, 2015)
    • Bilateral in 10-20% of patients (Nigrovic, 2016)
  • Children tend to present with limp and limited range of motion of the hip.
    • Children may also initially present with knee pain or thigh pain
  • Plain films of the hips help make the diagnosis, though tend to normal early in the course [unlike case above, which likely details later stage findings] (Nigrovic, 2016)
    • MRI helpful in diagnosis early in disease process as well as detailing prognosis (Dillman et al, 2009)
      • findings include: proximal femoral necrosis, delayed contrast enhancement, abnormalities in the proximal femoral physis
  • Referral to orthopedic surgeon important for long term management
    • Once diagnosed, children should be made nonweight bearing until seen by orthopedist (Nigrovic, 2016)
  • Ongoing management is symptomatic (anti-inflammatory meds, physical therapy, limited activities), though there is a paucity of evidence to guide recommendations.

Faculty Reviewer: Alison Riese, MD


Case courtesy of Dr. Bruno Di Muzio, From the case rID: 12153

Dillman JR et al. “MRI of Legg-Calve-Perthes Disease.” American Journal of Radiology. 2009;193(5)1394- 1407.

Herman MJ et al. “The Limping Child.” Pediatrics in Review. 2015;36(5)184-197.

Nigrovic PA. “Overview of hip pain and childhood.” Accessed October, 2016.

Image of the Week: 10/17

While evaluating an otherwise asymptomatic, healthy adolescent in clinic, you note an irregular rhythm on exam. Given this finding, you order an EKG (shown below). What do you think?


EKG Courtesy of Life in the Fast Lane:

Diagnosis:  AV block: 2nd degree, Mobitz 1 (Wenckebach Phenomenon)


What is it?

  • Progressively lengthening of the PR interval and eventual “dropped QRS” complex, caused by increased refractory period of the AV node . The entire process tends to occur over 3-6 cardiac cycles (Doniger et al, 2006)
  • Following “dropped” beat, there is a diastolic pause, and cycle continues
  • Characteristically thought of as a “benign rhythm” found in asymptomatic individuals and there is low risk of progressing to third degree heart block. In fact, up to 10% of healthy will episodes of type 1, second degree heart block (Dickinson, 2005).
    • However, this may be seen in myocarditis, congenital heart disease, and following cardiac surgery

Created by:  Jason Mandell, MD

Reviewed by: Brian Lee, MD


Dickinson DF. “The Normal ECG in Childhood and Adolescence.” Heart. 2005;91:1626-1630

Doniger SJ et al. “Pediatric Dysrhythmias.” Pediatric Clinics of North America. 2006;53(1)85-105

Life in The Fast Lane:


Trouble in Paradise



Case: George is a 5 year-old boy presenting to an Emergency Department (ED) complaining of abdominal pain and loose stools following a recent tropical vacation. How should we proceed? Is there any way that we could have prevented this?

What is traveler’s diarrhea?

    1. Classic Definition: ≥ 3 unformed stools in 24 hour period with nausea, vomiting, cramps, fever, blood in stool (Stauffer et al, 1990)
      • For infants and young children, some authors define diarrhea as ≥ 2-fold increase in unformed stool (Ashkenazi et al, 2016)
    2. Moderate diarrhea: 1-2 loose stools per 24 hour period
    3. Mild diarrhea: 1 loose stool per 24 hour period
    4. Duration (CDC, 2016)
      • Viral : 2-3 days
      • Bacterial: 3-7 days
      • Protozoal: weeks to months

Etiology (Ashkenazi et al., 2016)


Electron Microscope Image of E. Coli (Pixabay Image)

    1. Bacterial: E. Coli (ETEC, EHEC, EAEC, etc), Campylobacter jejuni, Salmonella spp., Shigella spp.,  are the most commonly seen, though Aeromonas spp. increasingly noted (CDC, 2016).
      • Of note, E. Coli (O157:H7) [associated with hemolytic uremic syndrome] has not been described in traveling children (Mackell, 2005)
    2. Viral: rotavirus, norovirus, adenovirus
    3. Parasite: Giardia (most common), Cryptosporidium, Cyclospora, entamoeba (uncommon)
    4. Etiologic agent generally identified in less than ⅓ of cases



    1. General incidence: 10-40% of travelers (Pitzinger B et al, 1991), though can affect up to 70% of travelers depending on the location they were traveling in (CDC Yellow Book)
      • Highest risk in Asia, Sub-Saharan Africa, and Latin America (Hagmann et al, 2010)
    2. Young children at the highest risk and manifest most severely (Ashkenazi et al, 2016)
    3. Children visiting family and/or friends are at higher risk as compared to tourists


    1. Microbiologic identification is generally unnecessary
    2. If fever and colitis  think Campylobacter, Shigella, EHEC
    3. Predominance of upper GI symptoms  Giardia, isospora, cyclospora
    4. If recent antimicrobials  -> C. diff
    5. If ill, send cultures for salmonella

Role for Prevention? (Connor, 2015)

  1. Choosing food and beverages wisely while traveling has been the cornerstone of advice
    • Unfortunately, studies do not show benefit to this practice (Steffen et al, 2004)
  2. Hand hygiene very important
  3. For children older than 12 years old, bismuth subsalicylate has been shown to reduce incidence of traveler’s diarrhea by 50%
    • Inconvenient dosing: 2 tabs, four times daily
  4. Prophylactic antibiotics are not generally recommended
    • May be considered in “high-risk hosts” (e.g. immunosuppressed)

His dad asks: how should he treat this?


    1. Maintaining hydration is the most important treatment
      • Use urine output as a guide (if normal urine output, diarrheal illness is mild)
    2. If evidence of dehydration: Preferentially use oral rehydration solution (Desforges, 1990)
      • WHO solution made with: Glucose (20g/L), 3 salts (3.5g/L) [sodium chloride, potassium chloride, and sodium bicarbonate]
      • Rationale for use is intestinal co-transport of glucose and sodium
    3. Role of antibiotics
      • Warranted in severe diarrhea (>4 stools in 24 hr period, fever, blood/pus in stool)
        1. Azithromycin is treatment of choice (Ashkenazi et al., 2016)
        2. Rifaxamin for children ≥ 12 years old
        3. Fluoroquinolones (Note: not FDA approved for children)


      1. Diarrheal illness in children returning from travel is not uncommon
      2. Younger children at higher risk of significant morbidity
      3. Maintaining hydration is essential; utilize oral route
      4. Antibiotics not well studied, beneficial in severe cases
      5. For all traveler’s, utilize CDC’s Website to provide resources and guidance

Online Resources

  • CDC:

Faculty Reviewer: Michael Koster, MD


Ashkenazi S et al. “Travelers’ Diarrhea in Children: What have we learnt?” The Pediatric Infectious Disease Journal. 2016;35(6)698-700.

Connor BA. “Traveler’s Diarrhea.” CDC Health Information for International Travelers 2016. Ed. G. Brunette. Oxford University Press, 2015.  Print and Online

Desforges JF. “Oral therapy for Acute Diarrhea- The Underutilized Simple Solution.” NEJM. 1990; 323:891- 894.

Hagmann S et al. “Illness in Children After International Travel: Analysis From the GeoSentinel Surveillance Network.” Pediatrics. 2010. 125(5)e1072-e1080

Mackell S. “Traveler’s Diarrhea in the Pediatric Population: Etiology and Impact.” Clin Infect Dis. 2005;41(Suppl 8)S547-S552.

Pitzinger B et al. “Incidence and clinical features of traveler’s diarrhea in infants and children.” The Pediatric Infectious Disease Journal. 1991;10(10)

Stauffer WM et al. “Traveling with Infants and Small Children. Part III: Traveler’s Diarrhea.” Journal of Travel Medicine. 2002;9(3):141-50

Steffen R et al. “Epidemiology of Travelers’ Diarrhea: Details of a Global Survey.” J Travel Med. 2004;11(4)231-238.



“Water, water, everywhere…”



Case: Zoe is a 10 day old ex- full term female, born to a G1P0 →1 presenting with feeding difficulties. Per her mother, she is exclusively breastfed and had initially had been doing “ok” but for the last couple days, has been more sleepy than usual and not feeding as well. She also notes that during this time, her eyes have become a bit more yellow.


On exam, you note an infant in no distress, but she sleeps comfortably through your exam. Jaundice is appreciated. Vitals are normal, but you note she has lost 12% of her birth weight. Her HEENT is notable for a sunken anterior fontanelle. Her exam is otherwise benign. Concerned for hyperbilirubinemia and dehydration, you order a complete metabolic panel, which, among other abnormalities, is significant for a serum sodium of 165 meq/L.


Why is her sodium so high?

Diagnosis: Severe neonatal hypernatremic dehydration



  • In this case, the most likely etiology is ineffective breastfeeding (also termed lactation failure), which is a rare, but increasing cause of hypernatremic dehydration (Mortiz et al, 2002)
  • In all humans (not just neonates), hypernatremia results from one of two mechanisms: inadequate access to free water and/or an inability to concentrate urine
  • Breastfeeding failure leads to inadequate fluid intake, but is also related to the higher concentration of sodium in breast milk (Morton, 1994)


How do patients present? (Moritz et al, 2005)

scaleOver 70% of patients had > 10% weight loss


Signs at Presentation

% Of Infants (n=70)

Jaundice 81
Poor PO Intake 61
Decreased Urine Output 36
Fever 20

Table Adapted from Moritz et al, 2005


How common is this problem?

  • Neonatal hypernatremic dehydration is rare. A review of admissions to a major children’s hospital found that over 4 years, 1.9% of term and near term infants were admitted for hypernatremic dehydration (Mortiz et al., 2005)
  • Most commonly affects primiparous mothers


How should we treat?

  • The goal of treatment is to lower serum sodium in a slow and controlled fashion
  • Conventional teaching states that sodium should not be lowered faster than 0.5mEq/hr and in fact, recent studies suggest that correction faster than 0.5mEq/L/hr is independently associated with poor neurologic outcomes and seizures (Bolat et al, 2013)
  • Specifics (based on protocol detailed in Bolat et al)
    • Emergency Phase
      • Correct shock immediately (within 30 mins) with 10-20 cc/kg 0.9% saline
    • Rehydration Phase
      • Calculated Free Water Deficit
      • Composition of fluid for rehydration is dependent on serum sodium; remember, in patients with high serum concentrations, “normal saline” will be hypotonic (154 meq/L)
      • Serum sodium should be decreased by 0.5meq/L/hr over the first 24-48 hours
      • If a patient is urinating, add 40 meq potassium to fluids


What are the neurological outcomes?

  • In the aforementioned study (Bolat et al, 2013), researchers found that presenting serum sodium >160 meq/L was an independent predictor of mortality (OR: 1.9) and correction faster than 0.5 meq/hr was independently associated with an increased risk of seizures (OR: 4.3)
  • At 6 months of age, patients were screened with the Denver Developemental Screening Test II. Serum sodium > 165 meq/L on presentation was associated with worse outcome.


  • Neonatal hypernatremic dehydration is a rare complication of exclusive breastfeeding, primarily seen with primiparous mothers and  can have devastating consequences
  • Clinicians need to be aware of this complication and ensure infants  who are exclusively breastfed are followed closely to ensure adequate breastfeeding and weight gain
  • If hypernatremic dehydration is encountered, it is imperative to 1.) treat shock initially and 2.) ensure that serum sodium is NOT corrected faster than 0.5 meq/hour

Resident Reviewer: Marie Carillo, MD


  • Ahmed A et al. “Complications Due to Breastfeeding Associated Hypernatremic Dehydration.” Journal of Clinical Neonatology. 2014;3(3):153-157
  • Bolat F et al. “What Is the Safe Approach for Neonatal Hypernatremic Dehydration?” Pediatric Emergency Care. 2013;29(7):808-813
  • Moritz ML et al. “Breastfeeding-Associated Hypernatremia: Are We Missing the Diagnosis?” Pediatrics. 2005;116(3):e343-e347
  • Moritz ML et al. “Disorder of Water Metabolism in Children: Hyponatremia and Hypernatremia.” Pediatrics in Review. 2002;23(11):371-380
  • Morton J. “The Clinical Usefulness of Breast Milk Sodium in the Assessment of Lactogenesis” Pediatrics. 1994;93(5):802-806

Commercial Sexual Exploitation of Children (CSEC)

Post Created by: Anish Raj, MD

Case: A 15-year-old female, with a history of PTSD, presents to the ED for medical clearance after being AWOL (absent from care) from her group home for the past 3 weeks. What are critical components you should consider prior to making any disposition plans for this patient?

I.) Background (Smith, 2014)

  • Commercial Sexual Exploitation of Children (CSEC): the sexual abuse of a minor (< 18 years old) with remuneration in money, goods, or services—or the promise of money, goods, or services—to the child or a third-party for the sexual use of that child.
  • Note: CSEC is an umbrella term that encompasses child sex trafficking, escorting, survival sex, child pornography, stripping, etc.
  • Domestic Minor Sex Trafficking (DMST): the inducement of a commercial sex act of anyone under the age of eighteen by a controlling party (i.e. trafficker/exploiter/pimp) that takes place within U.S. borders and involves a child who is a U.S. citizen.
  • Note: Per the Trafficking Victims Protection Act (TVPA), in cases of child sex trafficking, the inducement of a commercial sex act of a minor (< 18 years old) is enough to meet criteria for trafficking. Force, fraud, or coercion do NOT have to be demonstrated.


II.) Epidemiology (IOM, 2013)

  • No consensus on estimates of incidence and prevalence
  • Most widely cited national estimate: 244,000-325,000 children are at risk for CSEC
  • Average age of initial involvement: 15 years old (Gibbs et al., 2015)
  • Rhode Island preliminary data: ~70 suspected cases over the past 3 years


III.) Risk Factors

  • *History of sexual abuse*: up to 70-90% of CSEC victims (Bagley & Young, 1987)
  • History of running away and/or truancy: 70% of street youth estimated to be involved in CSEC at some point (Estes & Weiner, 2001)
  • Child welfare (e.g. DCYF) involvement: 50-80% of CSEC victims (Walker, 2013)
  • Juvenile justice system (e.g. RITS) involvement
  • Adult (> 18 years old) “boyfriend”/“girlfriend”
  • Multiple sexual partners at present
  • Positive STI testing
  • Substance use


IV.) Physical Exam


  • Observation: are clothing and accessories congruent with age/time/season?
  • Tattoos: name branding? explicit? gang insignia?
  • Note: In Rhode Island, individuals must be > 18 years old to receive a tattoo or piercing in a licensed parlor.
  • Signs of physical abuse (including but not limited to head trauma, oral trauma, genital trauma, and cutaneous injuries)


V.) Screening Examples (no brief, validated screening tool currently exists)

  • Have you or any of your friends ever exchanged sex for money, a place to stay, food, or drugs?
  • Has anyone ever asked you to have sex with someone else or made you have sex when you didn’t want to?
  • Has anyone ever taken sexual pictures of you or posted such pictures on the internet? (Greenbaum et al., 2015)


VI.) What To Do If You Suspect CSEC

  • Understand that it is very common for patients to NOT disclose
  • Notify Aubin Center (i.e. page on-call physician) of suspected CSEC
  • Determine need for forensic evidence collection if acute assault has taken place
  • Consult Psychiatry for evaluation
  • Confirm with law enforcement that missing persons report was filed if patient had been missing
    • If no report was filed, communicate this information to DCYF due to concern for possible neglect by caregiver
  • File report expressing concern for suspected CSEC to DCYF Hotline
  • Complete PRE without hold and fax to DCYF
  • Order screening labs: urine pregnancy, urine gonorrhea, urine chlamydia, urine trichomonas, urine toxicology screen, RPR, hepatitis C, hepatitis B, and HIV
  • Consider administration of empiric STI antibiotic treatment (e.g. ceftriaxone, azithromycin, and metronidazole)
  • Consider administration of Plan B
  • Consider administration of HIV post-exposure prophylaxis (PEP) on a case-by-case basis in coordination with Aubin Center +/- Infectious Disease team
  • Determine safe disposition plan
    • Ensure patient has an outpatient appointment at Aubin Center if being discharged
  • Consult social work and Aubin Center if patient is admitted


Faculty Reviewer: Christine Barron, MD



  • Smith, Holly Austin. Walking Prey: How America’s Youth Are Vulnerable to Sex Slavery. New York: St. Martin’s, 2014. Print.
  • Institute of Medicine and National Research Council. Confronting commercial sexual exploitation and sex trafficking of minors in the United States. Washington, DC: The National Academies Press; 2013. Print.
  • Gibbs, D., Walters, J., Lutnick, A., Miller, S., & Kluckman, M. (2015). Evaluation of Services for Domestic Minor Victims of Human Tracking. Manuscript submitted for publication. Retrieved August 12, 2016, from
  • Bagley, C., & Young, L. (1987). Juvenile Prostitution and Child Sexual Abuse: A Controlled Study. Canadian Journal of Community Mental Health, 6(1), 5-26. doi:10.7870/cjcmh-1987-0001.
  • Estes, R., & Weiner, N. (2001). The Commercial Sexual Exploitation of Children in the U.S., Canada and Mexico. Retrieved August 12, 2016 from
  • Walker, K. (2013). Ending the Commercial Sexual Exploitation of Children: A Call for Multi-System Collaboration in California (USA, California Child Welfare Council). Retrieved August 12, 2016, from Welfare/Ending CSEC-ACallforMulti-SystemCollaborationinCA-February2013.pdf.
  • Greenbaum, J., & Crawford-Jakubiak, J. E. (2015). Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims. Pediatrics, 135(3), 566-574. doi:10.1542/peds.2014-4138.

Getting the Lead Out


Rosalie is a 2 year-old girl who comes in for her regular checkup. At the end of the visit, when you hand a lab slip to check hemoglobin and lead levels, her mom asks, “Why should we check her blood again? We did that last year and everything was fine. Last time, they had to try 3 different times to get blood, and I really don’t want her to get stuck again.”

What do you say?



Why should we care about elevated blood lead levels (BLLs)?

  • Toxic Effects to the Following Organ Systems [Papanikolaou NC et al, 2005]:

    • CNS
      • Developmental Delay: Decline in IQ, reduced academic performance, hyperactivity, increased aggression, etc (can been seen at levels ≥35μg/dL).
      • Seizures
      • Encephalopathy (BLL usually > 100μg/dL)
    • Gastrointestinal
      • Constipation
      • Abdominal Pain
    • Hematologic (effects observed at levels as low as 10 μg/dL)
      • Microcytic Anemia
    • Cardiac, Renal




  • According to the CDC, in 2014 4% of children tested in the United States had elevated BLL (>5 μg/dL)
    • In Rhode Island, slightly more children (5%), had elevated BLLs
  • Unfortunately, of the >24 million children <72 months, only 10% were actually screened.
    • In Rhode Island, 39% of children <72 months were screened
  • Elevated Lead levels are more likely to affect children who are: [MMWR, 2013]
    • Black, non-Hispanic
    • Live in houses built before 1950
    • Receive Medicaid
    • Low socioeconomic status
  • Where is this lead located?
    • Lead Paint (used in older houses; imported hand painted dishes, toys)
    • Contaminated Soil (usually where leaded gasoline deposited)
    • Water (Lead pipes); well water
    • Natural Remedies (certain health tonics, digestive aids, or colic remedies)

When should you check Rosalie’s blood lead level?

  • According to the CDC:
    • Universal screening of all children, at 1 and 2 years of age (of note, ALL children on Medicaid MUST be screened)
  • In Rhode Island it is mandatory to screen all children who are under 36 months at least twice  ( This is usually done at 12 and 24 months
    • Children should be screened annually through 6 years of age
      • After 2 negative blood levels, use risk assessment and screening tools to guide workup.

Her lead level returns elevated, what should you do?

  • Consult with your State’s Lead Prevention Program Recommendation. Table below is from Rhode Island Department of Health
Venous Blood Level Confirmation Interval Recommended actions for Primary Care Providers
< 5 μg/dl No confirmation needed Provide Lead education and continue to assess for lead exposure
5- 14 μg/dl Retest within 3 months ·       Explain lead level to parents

·       Assess Nutrition

·       Test Siblings < 6yo

·       Provide Lead Education

15-19 μg/dl Retest within 3 months ·       Same recommendations as above

·       Dept. of Health will refer to lead center

20- 44 μg/dl Retest within 1 week ·       Refer for evaluation and treatment to local lead clinics
≥ 45 μg/dl Repeat Immediately ·       As above, but consider hospitalization

Adapted from Rhode Island Department of Health Lead Screening and Referral Guidelines. Updated September 2013.

Rosalie’s lead level is 56, which is confirmed on repeat testing. What is the next step?

Moderate Intoxication (45-69mcg/L)

  1. Once level is confirmed, chelation should be started as follows:
    1. DMSA (Succimer)- this is the oral version of dimercaprol
    2. CaNa2EDTA- for children who cannot tolerate DMSA
    3. D-penicillamine (third line agent for children who cannot take 1 or 2 due to adverse affect).

Severe Intoxication (70mcg/L or encephalopathy)

  1. Hospitalize
  2. Repeat labs (especially serum lead); if confirmed
  3. Chelate
    1. Dimercaprol (BAL)
    2. Calcium disodium edetate (CaNa2EDTA)
  4. Monitor
  5. Disposition dependent on availability of follow-up, ensuring lead free household


  • No blood lead level is considered safe
  • Lead intoxication remains an important cause of preventable developmental delay
  • All children should be screened at 12 and 24 months of age
  • Know your state’s guidelines on Lead screening and Referral Guidelines!


Faculty Reviewers: Shuba Kamath, MD; Chandan Lakhiani, MD


Lead Poisoning in Popular Culture



“Blood Lead Levels in Children Aged 1–5 Years — United States, 1999–2010.”  Morbidity and Mortality Weekly Report. 2013;62(13);245-248

Chandran L et al. “Lead Poisoning: Basics and New Developments.” Pediatrics in Review. 2010;31(10)399- 406.

Dietrich KN et al. “Effect of Chelation Therapy on the Neuropsychological and Behavioral Development of Lead-Exposed Children After School Entry.” Pediatrics. 2004;114(1)19-26.

Lowry JA et al. “Childhood lead poisoning: Management.”  UpToDate. Accessed July 10, 2016.

Papanikolaou NC et al. “Lead toxicity update. A brief review.” Med Sci Monit.. 2005;11(10)RA329-336.

Schmidt, Silke and Dee Hall. “Failure at the faucet: Lead in drinking water poses danger for children, pregnant women.”

“Lead Screening and Referral Guidelines.” Rhode Island Department of Health. September 2013

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