Pediatrics - SSM Cardinal Glennon Children's Medical Center

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DiversionsAndrew Sutton Physician Services Manager2008 Nalle Winery Reserve ChardonnayThe weather is warming up, and it’s time for long evenings on the patio with a group of good friends. One of thefriends you should bring to the party is the 2008 Nalle Reserve Chardonnay.Nalle Winery is a tiny, family-owned operation in the Dry Creek Valley in Sonoma’s wine country. So tiny in fact,that it’s literally a mother, father and son that run the winery and make the wine. I had a chance to visit them this pastsummer and fell in love with their laid-back attitude, and their simply outstanding Burgundy style wines.The grapes are sourced from the Hopkins Ranch in Russian River Valley, where cool temperatures and fog allow thegrapes to develop slowly with just the right amount of acidity, and elegance. This wine shows fantastic nose of ripefruit, with a touch of vanilla, and a little bit of apple. Its mouth feel sways a little toward medium than light, showingthe kiss of oak from a short barrel fermentation, balanced by a touch of crispness and acidity. This is a very wellbalancedwine that is an absolute joy to consume. Available through the Nalle website for $42.00, I would put thiswine up against a Premier Cru Burgundy any day of the week. YUM! www.nallewinery.comPediatric Brains More Vulnerable to Injury,Concussion Clinic Opens at SSM Cardinal GlennonAn increased amount of research over the years proves that pediatric brains are more vulnerable toinjury and pediatric patients experience more severe symptoms and require more time to recover froma concussion. The Missouri Interscholastic Youth Sports Brain Injury Act (“A youth athlete suspectedof sustaining a concussion or brain injury must be removed from competition at that time andfor at least 24 hours. He or she must not return to competition until being evaluated by alicensed health care provider trained in the evaluation and management of concussions.”)is a Missouri state law that requires children and adolescents to be seen immediately byconcussion experts.Research findings across multiple disciplines on pediatric concussions prompted theopening of SSM Cardinal Glennon’s new multidisciplinary concussion clinic. NeurologistRaman Malhotra, MD, and Neuro-Psychologist Stacey Woodrome, PhD, are the clinic’smain providers.Appointments are available every Wednesday from 8 a.m.-noon.Please call 314-577-5338 for an appointment.Practice Points:Managing Headaches in ChildrenSean Goretzke, MDDepartment Director of Child Neurology, SSM Cardinal Glennon Children’s Medical CenterAssistant Professor of Neurology, Saint Louis University School of Medicine4Headaches are not a rare occurrence in the pediatric population. Up to 60 percent of children will havea headache severe enough to seek medical care by the age of 18. Headache is consistently among the top10 reasons children visit the emergency room. As such a common occurrence, the most important initial job for the managingphysician is to sort out which children have headaches due to a dangerous cause and which are symptoms of what are termed“primary headache disorders.” It is important to remember that very basic things can cause headache such as viral or bacterialrhinosinusitis, eye strain, skipping meals and not getting enough sleep.
Acute HeadacheWith an acute headache, especially if referred to as “the worstheadache of my life”, we drift back to our medical school trainingand worry that a subarachnoid hemorrhage from a rupturedaneurysm may be the cause. Additionally, whether they tellyou or not, just about every parent of a child with recurrentheadaches is concerned that their child may have a brain tumor.Luckily, these are incredibly rare causes of headache in kids,though sometimes parental anxiety makes it difficult to keep anobjective eye on the facts at hand regarding the headache, andleads to a prompt emergency room or neurologic referral. Weare, of course, more than happy to help, though this article willtry to present some suggestions to help navigate these waters.MigraineThe “worst headache” scenario can be especially worrisome if itis the child’s first headache. In reality, most of these children turnout to have migraine, and this is, in fact, their first migraine.Younger children who are not used to severe degrees of pain maybe screaming for minutes to hours from a migraine headache.Often the patient’s family calls in to the office or after-hourspager, and you don’t have the luxury of examining the child. Ingeneral, if this headache occurs during exertion, or if it is associatedwith fainting, they should be taken to the emergency roomimmediately. Even then, it is most likely a migraine headache,though prompt medical attention is recommended. If the childhas had similar headaches in the past, though not as severe asthe current headache, and the child can tolerate oral medication,an appropriate dose of non-steroidal anti-inflammatory can berecommended. If there is not improvement within an hour ortwo, the child can be directed to the office for other medicationoptions.For the child with acute, intermittent, severe headaches, itis important to ask for other symptoms of migraine. Theseare similar to adults and include a throbbing quality, nauseaand/or vomiting, photo- and phonophobia and aggravationwith exercise. These headaches typically last 1-72 hours, andcontrary to adult criteria, can be bilateral in location. Thoughmost migraines occur in the fronto-temporal region of thehead, they can also occur in the posterior region in isolation.If the child meets criteria for migraine, it becomes appropriateto find an abortive agent. This can be as simple as a dose ofacetaminophen or ibuprofen (which are surprisingly effectivein children with migraine). There are many other options(both over the counter and prescription) that can be tried. Thefamily of triptan medications can safely be used in childrenwith migraine. These were initially not approved for children(though gaining acceptance over the years), not due to concernsover safety, rather because of the high rate of placebo effect inpediatric studies. Although as a child neurologist, I have usedthese medications down to age 6, effectively and safely, it isprobably reasonable for a primary care physician to limit the useto children ages 10-12 and up.Even if migraines are responsive to abortive agents, they canstill be quite interfering with the child’s life. If the patient isexperiencing more than 4-8 days per month where the headacheis affecting their ability to function normally, considerationshould be given to using a preventer (prophylactic) medication.These medications are taken daily (in addition to their abortiveagent as needed), with the goal of decreasing headaches down to1-3 days per month, or less. It is important to let families knowthat this will not eliminate all headaches, but should certainlymake them a more manageable and less frequent occurrence.Chronic Daily HeadacheThe last scenario is that of the child with “chronic dailyheadaches (CDH).” This refers to headache occurring morethan 15 days out of the month, and can often be an “all day,every day” phenomenon. This is a challenging condition, andcan take quite a lengthy office visit (or visits) to sort out. Theyare often multi-factorial in nature, and the patient may have afew different types of headaches involved in the process. Thisis probably the most common patient referred to our childneurology group, not only for the lengthy nature needed forthe visit, but also for ongoing parental frustration that “nothinghas worked.”It is important to identify any poor “headache hygiene” habitsthat may be a contributing factor in children with CDHs. Thisincludes amount and quality of sleep, eating habits, caffeineintake, overuse of pain relieving medication, prior or currentconcussive head injuries (often overlooked) and stress levels athome or school. Addressing these can often lead to a significantimprovement. For headaches that persist, especially if severe,features of migraine should continue to be sought out, andpreventative treatment of migraine may be of great benefit.“Red flags” for children with chronic headaches that shouldprompt consideration for imaging studies and/or pediatricneurology referral include:• Associated chronic illness (such as inflammatory orautoimmune disorders, an immune compromisedstate, history of systemic or CNS malignancy andneurofibromatosis)• Progressive severe worsening of the headache or newheadache type in someone with prior headaches• Headaches waking the child from sleep consistently• Associated systemic signs such as fever or weight loss• Young age (under 3 y/o)• Duration of headaches less than three months• Progressive neurologic complaints to include progressiveloss of vision (not simply visual aura’s of migraine),personality changes, new speech deficits, cognitivedecline and balance difficultiesAt SSM Cardinal Glennon, we are happy to provide expertmanagement of children with chronic headaches that areaffecting their ability to lead a happy and productive life. Tomake an appointment with one of our neurologists, please call314-577-5338 or 314-678-5444.5
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Pediatrics - SSM Cardinal Glennon Children's Medical Center

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