In treating adolescents with major depressive episode(MDE), the only medication which has a positive risk-benefit ratio in patients younger than 18 years is the SSRI fluoxetine (Prozac). Please see Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. (Whittington CJ et al. Lancet. 363(9418): 1341-5, 2005 Apr 24)for more information.

Sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa) are all SSRI's. Venlafaxine (Effexor) is an SNRI.

The diagnostic criteria for a major depressive episode are:

A. At least 5 of the following, during the same 2-week period, representing a change from previous functioning; must include either (a) or (b):
(a) Depressed mood
(b) Diminished interest or pleasure
(c) Significant weight loss or gain
(d) Insomnia or hypersomnia
(e) Psychomotor agitation or retardation
(f) Fatigue or loss of energy
(g) Feelings of worthlessness
(h) Diminished ability to think or concentrate; indecisiveness
(i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide
B. Symptoms do not meet criteria for a mixed episode.
C. Symptoms cause clinically significant distress or impairment of functioning.
D. Symptoms are not due to the direct physiologic effects of a substance or a general medical condition.
E. Symptoms are not better accounted for by bereavement.

Escitalopram is also currently FDA approved for MDD in children 12-17.

U.S. Food and Drug Administration. Center for Drug Evaluation and Research. Lexapro. Available at: www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Overview&DrugName=LEXAPRO.

The most likely diagnosis given the above clinical picture is Kawasaki disease. Kawasaki disease is a vasculitis primarily affecting medium-sized arteries and is the leading cause of acquired heart disease in children. The etiology is unknown. It is most common in children under the age of 5, with a peak at age 2 and 3 years, more common in children of Asian descent.

The diagnostic criteria includes:
A) Fever persisting five or more days
B) Four of the following five features:
1. Bilateral non-purulent conjunctivitis
2. One or more changes to mucous membranes (cracked lips, strawberry tongue, erythema of the oropharynx)
3. One or more extremity changes (erythema, edema, peeling)
4. Polymorphous rash, primarily truncal
5. Cervical lymphadenopathy >1.5cm in diameter

Serious cardiac complications of Kawasaki disease can occur, including coronary artery vasculitis and aneurysm formation which may lead to arrhythmias, infarction, congestive heart failure and death.

It is unlikely Scarlet fever as there is usually a history of Group A Strep infection. Henoch-Schonlein Purpura usually presents with abdominal pain, arthritis, abdominal pain and hematuria.

Epstein-Barr virus (infectious mononucleiosis) usually occurs in adolescents and young adults. It often presents with fever, fatigue and sore throat. Other presentations include:weight loss, malaise, pharyngeal inflammation and petechiae. On physical exam, there is usually lymphadenopathy, splenomegaly, hepatitis and hemolysis.

Meningococcemia is systemic infection or sepsis by Neisseria meningitidis. Children with meningococcemia present septic looking with a petechial/purpuric rash and/or meningitis. This is a life-threatening infection that must be treated promptly. Paulette presented with a 5-day history of fever and is not septic looking, therefore meningococcemia is unlikely.

Patients with tetralogy of fallot can develop acute episodes of hypoxia or "tet spells." During these episodes, the key to treatment is increasing the systemic vascular resistance (SVR) and decreasing the pulmonary vascular resistance (PVR) to prevent right-to-left shunting and encourage pulmonary blood flow.

Placing patients in the knee-chest position or squatting position will increase the SVR. Medical treatments include fluid bolus, oxygen (decrease PVR), phenylephrine (increase SVR) and propanolol (decrease muscular spasm).

Digoxin will increase the cardiac contractility but will not solve the underlying problem of right-to-left shunting.

During tet spells, patients can lose the murmur associated with pulmonary stenosis due to the decreasing pulmonary flow. With severe tet spells, unconsciousness, convulsions and death may occur.

While oxygen is often used for TOF patients during a spell, it will be unlikely to make a large difference in their saturations. It is much more important to keep the child calm.

The most likely diagnosis is otitis externa and otitis media due to the purulent exudate draining from the ear canal, inflammation and erythema around the ear.

Cellulitis can develop due to uncontrolled otitis externa. Cellulitis is a infection of the skin, usually caused by streptococcal or staphylococcal infections. It results in severe inflammation and localized edema.

Abscess would be less likely due to the lack of a visible mass in the mastoid region (most likely region of abscess secondary to acute otitis media).

Actinic keratosis are small rough or scaly areas of the skin due to solar damage from prolonged sun exposure. This lesion is unlikely in a young child.

Pulmonary fibrosis is the most serious complication of bleomycin therapy. It usually presents with cough, shortness of breath and upon investigations pulmonary function tests demonstrate lung disease.

Adriamycin can lead to cardiac toxicity long term. The effects are dose related and cumulative over time.

Infertility is a side effect of ABVD therapy but it is difficult to determine which drug is primarily responsible. Secondary malignancies can also occur with ABVD treatment however like infertility, the sole causative agent is difficult to discern. Both chemotherapy and radiotherapy likely play a causative role.

Please see here for an article on Hodgkin's disease: http://www.emedicine.com/ped/TOPIC1019.HTM

Celiac disease is an immune-mediated inflammatory disease that results in destruction of the absorptive villi of the small intestine. Children with Celiac Disease usually present between 6-18 months with diarrhea, vomiting, irritability, poor appetite, decreased height and weight.

Patients with Celiac disease must eat a gluten-restricted diet for life. Gluten is found in barley, rye, oats and wheat (BROW). Rice and corn are substituted into the diet and patients must be careful to read all labels for gluten.

Children with atrial septal defects have a characteristic fixed split S2 and a pulmonic systolic ejection murmur (SEM). Children are usually asymptomatic unless the lesion is large. Patients with ASD's are generally corrected surgically between the ages of 2-5 if symptomatic.

Ventricular septal defects have characteristic holosystolic murmur at LLSB and a mid-diastolic rumble at the apex. The size of the VSD is inversely related to the intensity of the murmur. Unless large, children are usually asymptomatic.

Children with pulmonary stenosis have a SEM at ULSB, widely split S2 and pulmonary ejection click. Pulmonary stenosis is usually due to a valvular obstruction that is surgically corrected if severe.

Children with a patent ductus arteriosus have a continuous "machine-like" murmur best auscultated in the left infraclavicular area. A PDA is generally closed with indomethacin or via catheter/surgery if the patient is symptomatic. PDA's are very common in premature infants.

The murmur associated with ASD is due to increased blood flow through the pulmonary valve, not blood flow through the ASD. The fixed S2 is due to the increased pulmonary blood flow and is always a sign of concern.

Caput succedaneum is a serosanguineous, subcutaneous, extraperiosteal fluid collection under the soft tissues of the scalp. A cephalohematoma is subperiosteal collection of blood between the skull and periosteum due to rupture of blood vessels. A cephalohematoma does not cross suture lines; a caput succedaneum extends across the midline and over suture lines.

An subgaleal hemorrhage is blood between the skull periosteum and aponeurosis. The majority of cases is due to vacuum applied during delivery and gradually develops 12-72 hours after delivery. It is unlikely to be present immediately after birth.

An epidural hematoma is blood between the skull and dura mater. Epidural hematomas do not cross suture lines and are unlikely to be present in a newborn.

See article: http://www.emedicine.com/ped/TOPIC2836.HTM

Breastfeeding is encouraged to be done "on-demand" for the infant, especially early until the milk supply is established.

There are certain contraindications to breast-feeding that include particular maternal infections (ex. HIV, active TB), maternal substance abuse, certain medications (ex. warfarin, chloramphenicol, chemotherapeutic agents) and infants with galactosemia (lack appropriate enzyme to metabolize lactase).

Breast-fed infants do not require iron supplementation until 6 months. At this time, pureed or liquidized foods are encouraged to be introduced. Mothers are encouraged to continue breastfeeding and can begin weaning at 6 months. It is important that mothers do not alternate between breastmilk and formula - this can lead to difficulties with milk production.

A characteristic feature of older children with tetralogy of fallot is squatting. By squatting, the peripheral vascular resistance is increased, decreasing the magnitude of the right-to-left shunt through the VSD and decreasing the mixing of oxygenated and deoxygenated blood.

http://www.emedicine.com/med/TOPIC3579.HTM