Vaginal problems

Vulvitis

Prepubertal girls have a relative lack of estrogen and are thus prone to vulvitis. It is characterised by an inflamed, irritated vaginal orifice, often with a foul itchy discharge.

There can be pain or discomfort on micturition. It can be caused by:

• poor hygiene

• threadworms

• excessive inappropriate washing

• atopic or seborrheic eczema

• specific infections, e.g. streptococcal infection

• rarely candida, only after a course of antibiotics

• sexual abuse

A full history and investigations often provide a few clues to the etiology of the condition. Threadworms are fairly common as a cause of vulval itching, especially at night. Any specific conditions should be treated appropriately and the child and parent should be given advice on appropriate bathing and clothing.

Vulvovaginitis

A girl who has a discharge associated with the vulvitis has vulvovaginitis. The commonest causes vary with the age of the child. Infectious vaginitis is more common in sexually active adolescents and fungal infections are also more common owing to the more acid pH at this age. Children can also acquire infections such as Chlamydia trachomatis, gonorrhea and trichomonas via the birth passage or from sexual abuse. Non-specific vulvovaginitis is most common between the ages of 2 and 6 years, especially in the overweight girl. This has several causes, including:

• infection such as Staphylococcus aureus, Hemophilus influenzae, Gardnerella vaginalis

• sexually transmitted disease

• foreign body (rare)

• non-specific

Child sexual abuse should be borne in mind and excluded if possible. Specific infections are treated and general advice given as for vulvitis.

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Scrotal Problems in Pediatric

Acute enlargement or pain in the scrotal area is an important clinical sign as it may signal a surgical emergency. Boys with either of these symptoms need to be seen promptly because of the risk of testicular torsion. Testicular torsion may result in infarction of the testis in 6–12 hours if there is progressive obstruction to the blood supply.

The key questions that direct and inform the management are:

• whether this is a painless or painful problem

• whether it is associated with localized or generalized swelling.

Scrotal pain

a. Spermatic cord torsion

Torsion is the most important cause of scrotal pain. It is most common in early puberty, but can occur at any age. An unusual attachment of the testis within the tunica vaginalis results in the testis lying transversely and this predisposes to twisting. Clinically there is an abrupt onset of pain in the testicle often after trauma or exercise.

The pain is sharp and is often accompanied by systemic symptoms such as nausea and vomiting. On examination there is a high riding, tender testicle which is made more uncomfortable by elevation. There is a knot of blood vessels at the upper margin, which may be confused with epididymitis. Classically, there is an absent cremasteric reflex on the affected side. If the torsion is allowed to continue, there is increasing scrotal edema and inflammation, which obscure the landmarks.

If there are strong clinical signs of torsion then surgical exploration is indicated. The purpose of surgery is to untwist the affected testicle and anchor the opposite testicle (orchidopexy). Imaging studies are done only when the clinician is sure that torsion does not exist and is seeking supporting evidence. Imaging investigations can be either a nuclear testicular scan or color Doppler sonography. Either is acceptable though sonography is less sensitive.

b. Torsion of the testicular appendage

There are five vestigial appendages associated with the testis. Torsion can occur of any of them, usually in boys aged 7–12 years. The onset of pain is slow and milder than torsion of the spermatic cord. There are no systemic symptoms but usually only slight swelling of the testis. There may be a bluish discoloration in the upper scrotum (‘blue dot sign’). A nuclear scan will show increased blood flow in the upper region, which can be confused with epididymitis. The treatment is usually analgesia, bed rest and scrotal elevation.

c. Epididymo-orchitis

This condition occurs more commonly in adults and adolescents and is generally rare in children. Inflammation of the epididymi can be viral (adenovirus, mumps or Epstein-Barr virus) or occasionally bacterial in association with anatomical problems of the urinary tract. The possibility of spermatic cord torsion must be considered. Urinalysis may show mild pyuria. A nuclear scan will show increased blood flow to the epididymis. Treatment is supportive. Antibiotics directed to common urinary pathogens are used when bacterial infection is suspected.

d. Trauma

Trauma to the scrotum is usually a precisely remembered event in a boy’s life. If there is no history, another cause should be sought for scrotal pain. The mechanism of injury is often straddle type such as falling astride a bicycle bar. It is generally rare in prepubertal children because of the small size and mobility of the testes. There is often overlying bruising and, if severe enough, a traumatic hematocele. Surgical evacuation may be required if there is a significant collection of blood. In milder cases, cold compresses and analgesics suffice.

e. Other causes

The vasculitic process of Henoch-Schönlein purpura can involve the spermatic cord and testicle causing acute pain and swelling. Children typically have a purpuric rash on the buttocks and legs, which is diagnostic. Treatment in most circumstances consists of rest and pain relief, although severe testicular swelling may be an indication for steroid treatment.

An incarcerated inguinal hernia can also cause acute scrotal pain. There is often a history of intermittent groin swelling, which improves spontaneously. On examination a hernia is detected and cannot be reduced manually. If allowed to persist it can look very much like an acute torsion of the testis with systemic symptoms. Imaging with Doppler sonography or testicular scan can help clarify the cause. Surgical exploration and treatment is required.

Painless scrotal swelling

a. Hydrocele

Hydrocele is a collection of fluid between the tunica vaginalis and the testicle. In the first year of life the process vaginalis often closes and the hydrocele resolves. It often presents as a clear, bluish swelling in the region of the testicle. If it shrinks with gentle pressure, then there is a hernia component. Surgery is not usually advised before 1 year of age since many spontaneously resolve. If the hydrocele persists, or if there is a hernia component present, then surgery is recommended.

b. Varicocele

This is a collection of enlarged spermatic cord veins. It is more common in adolescents and on the left side. It is most obvious in the standing position and occasionally causes pain, especially with exertion. In most cases surgery is not required unless there are symptoms of atrophy of the testes (which is rare).

c. Other causes

An uncomplicated reducible inguinal hernia can cause intermittent testicular swelling. This often requires elective surgical repair because of the risk of incarceration. Acute scrotal edema is a form of urticaria. It starts in the scrotal area and can extend posteriorly. The cause of this is unknown but may include an insect bite allergic reaction, cellulitis or contact dermatitis. Almost all children with this condition are prepubertal. Treatment is symptomatic.

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Penile Problems in Pediatric

Phimosis

Phimosis is a tightness of the foreskin so that it cannot be drawn over the glans. It is most logically defined as either physiological or pathological. Physiological phimosis occurs because of the inability to retract infantile foreskin, owing to congenital adhesions between the glans and foreskin. By age 2–3 years, these adhesions break down and retraction becomes possible. However, around 6% of boys still have physiological phimosis at age of 10–11 years. 

Phimosis

Pathological phimosis occurs when the foreskin cannot be retracted after it has previously been retractable. Clinically this results in ballooning of the foreskin during urination. There may be mild obstruction to urinary flow or recurrent balanitis. Circumcision may be recommended if any of these pathological conditions are present.

Paraphimosis

Paraphimosis is a clinical condition that occurs when the foreskin is retracted and remains proximal to the glans penis. In this position the foreskin becomes progressively swollen due to vascular obstruction and may actually strangulate the glans. This situation will occur after forced retraction of the foreskin (e.g. for catheterization) or vigorous cleaning. If allowed to persist, increasing edema makes reduction progressively more difficult. The usual treatment is manual reduction. A local anesthetic block of the dorsal nerve of the penis is inserted. The foreskin is compressed to reduce the edema and then the foreskin is reduced by pressure on the glans.

Paraphimosis

Treatment depends on the age and degree of discomfort that the child is experiencing. If the swelling has been present for a prolonged period, then reduction may need to be under conscious sedation. Rarely reduction with accompanying circumcision under general anesthetic is required.

Posthitis/balanitis

Posthitis (inflammation of the prepuce) is more common than balanitis (inflammation of the glans). It is less common in children than in adults. In most cases the cause is infectious in origin although contact irritation, allergy and trauma may also be contributing factors. 

The treatment is directed towards the causative organism obtained by swabbing and culture. Mild cases usually respond to twice daily baths with gentle retraction of the foreskin along with a topical antibiotic ointment such as Polysporin. In more severe cases (inflammation involving more than a third of the shaft of the penis), treatment is usually with an oral broad spectrum antibiotic that is effective against uropathogens and staphylococcus (e.g. amoxycillin and clavulinic acid). This is in addition to cleaning and regular baths. These latter simple measures can prevent the recurrence of balanitis.

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Hypertension in Pediatric Emergency

Transient hypertension can occur in a child as a result of stress, fear or pain. Blood pressure (BP) measurements repeated on several different occasions (at least three) are required to diagnose hypertension. The cuff bladder should cover at least 3/4 of the child’s arm length, and the child should be quiet and calm. In children with measured high BP, it is important to differentiate between those who have immediately dangerous hypertension and those who may have long-standing hypertension. In these patients a search for a possible underlying cause should be made. Table 9.3 shows the upper 95th centile measurements for blood pressure.

Causes of hypertension

The causes of hypertension break down into essential hypertension and secondary causes. Secondary causes fall into a few main groups, depending on the system of origin.

These include:

• Renal (75%): postinfectious glomerulonephritis, chronic glomerulonephritis, obstructive uropathy, reflux nephropathy, renovascular, hemolytic uremic syndrome, polycystic kidney disease

• Cardiovascular (15%): coarctation of the aorta

• Endocrine (5%): pheochromocytoma, hyperthyroidism, congenital adrenal hyperplasia, primary hyperaldosteronism, Cushing syndrome

• Other (5%): neuroblastoma, neurofibromatosis, steroid therapy, raised intracranial pressure.

History

The history essentially should contain details of the family history (e.g. pheochromocytoma) and of genitourinary symptoms.

The examination must include the height and weight, blood pressure measurements of both upper and lower limbs, and a full neurological examination. .

Causes of secondary hypertension

• Appearance: Cushingoid, obese

• Skin: café-au-lait spots, neurofibromas, hirsutism, vasculitis

• Fundoscopy: hypertensive retinopathy

• CVS examination: left ventricular hypertrophy, murmurs (particularly interscapular)

• Abdomen: renal/adrenal masses, renal bruits

Investigation

a. Initial investigations should include:

• urine analysis

• urine microscopy

• blood urea and electrolytes

• creatinine

b. Further investigations may include:

• urinary catecholamines

• chest X-ray

• ECG

• renal ultrasound

• gluconate scan

• plasma renin pre- and post-captopril

• thyroid function tests

• cortisol/aldosterone levels

• 17-hydroxyprogesterone

• renal angiography.

Management

a. Asymptomatic hypertension

No urgent treatment is required for asymptomatic hypertension. The child can be investigated and managed as an outpatient and should be referred to the general pediatric outpatient clinic.

b. Acute severe hypertension

These patients require admission to ICU for urgent treatment. Hypertensive encephalopathy presents as severe headache, visual disturbance and vomiting, progressing to focal neurological deficits, seizures and impaired conscious state, with grossly elevated BP, papilledema and retinal hemorrhages. These patients almost always have chronic renal disease and are on dialysis. The differential diagnosis includes uremic encephalopathy and metabolic disturbance. BP should be lowered in a controlled fashion, with anticonvulsants given for seizures.

Antihypertensives. The choice includes the drugs listed below, although this is not an exhaustive list:

• Intravenous labetalol: 0.2 mg kg−1 initially; later by i.v. infusion of labetalol 0.5–3 mg/Kg weight per hour. It should be avoided if there is heart failure, asthma or bradycardia.

• Intravenous hydralazine: 0.1 – 0.2 mg/Kg weight  (max. 10 mg) stat, then 4–6 micro grams/Kg weight  per minute (max 300 micrograms per min). It may cause tachycardia, nausea and fluid

retention.

• Oral captopril: 0.1 mg/Kg weight  initially, increasing to a maximum of 1 mg/Kg weight  (max. 50 mg). Thereafter 0.1–1.0 mg/Kg weight  per dose 8-hourly. Captopril is usually effective within 30–60 minutes.

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Hematuria in Pediatric Emergency

Hematuria is the presence of red blood cells in the urine. The presence of 10 or more RBCs per high-power field is abnormal. Urinary dipsticks are very sensitive and can be positive at less than five RBCs per high-power field. In the emergency department it is important in evaluating a child with hematuria to identify serious, treatable and

progressive conditions

.

Red or brown urine does not always indicate hematuria. The discoloration may be as a result of hemoglobinuria, myoglobinuria, some medications and some food. Urate crystals are commonly present in the urine of newborn babies. They can produce a red discoloration of the nappy (‘brick dust’ appearance), which is sometimes mistaken for blood. Blood in the urine can come from sources other than the urinary tract (e.g. vaginal hemorrhage, rectal fissure).

Causes of hematuria

Common causes for microscopic hematuria include an association with viral infections, UTIs, trauma and Henoch-Schönlein purpura. Common causes for macroscopic hematuria include the above, but macroscopic hematuria is more likely to come from the bladder or urethra. Symptomless or ‘benign hematuria’ can occur frequently in children without growth failure, hypertension, edema, proteinuria, urinary casts or renal impairment.

Investigations

The investigation and management of hematuria in Pediatric

Treatment

Many children with isolated microscopic hematuria require no immediate investigation and simply need to be checked to see if the problem persists. This should be arranged with the general practitioner or through outpatient clinic if the family do not have a GP. In the setting of an acute febrile illness, exclude UTI by urine culture and arrange for the urine to be tested again after the acute illness has passed.

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Nephrotic Syndrome in Pediatric Emergency

Nephrotic syndrome is a clinical disorder characterised by edema, proteinuria (>3g per day), hypoalbuminemia and hypercholesterolemia. Minimal change glomerulonephritis accounts for 80–85% of nephrotic syndrome in childhood. Complications include infections, thrombosis and renal impairment.

History

Edema is the primary feature. This may be subtle or gross and is usually noticed in the peri-orbital region, scrotum or labia. It may include, in addition, peripheral edema of the limbs and sacrum. The history is often of weight gain, poor urine output and sometimes of discomfort as a result of the edema. A history of preceding upper respiratory tract infection or diarrhea may be present.

Examination

Examination should confirm the presence of edema. Ascites and pleural effusions may be present when edema is gross. Peripheral perfusion and blood pressure should be assessed. Examination should include a search for signs suggesting the onset of complications such as infected ascites, renal vein thrombosis (e.g. enlarged renal mass, loin tenderness and marked hematuria) and cerebral vein thrombosis. Urinalysis should always be included to make the diagnosis as other causes of edema such as protein losing enteropathy or cardiac failure may occur.

Investigation

Urinalysis usually shows +++ or ++++ protein on dipstick. The degree of proteinuria is variable and is usually of the selective type. Microscopic hematuria is present in 15–20% of patients with minimal change nephrotic syndrome. Microscopy of the urine may show red blood cells or granular casts, which suggests the alternative diagnosis of chronic glomerulonephritis as the underlying cause for nephrotic syndrome.

A timed collection of urine for protein excretion is not necessary when the diagnosis is clear. Blood urea and creatinine tests are important to establish the presence or absence of renal impairment. Blood electrolytes, total protein, albumin, globulin and cholesterol should also be measured.

Treatment

All children should be admitted to hospital with their first presentation of nephrotic syndrome. With relapses, they can sometimes be managed as outpatients after consultation with their treating physician. The components of the treatment will be considered individually

a. Albumin

In nephrotic syndrome, acute renal impairment is due to renal hypoperfusion. Albumin is the treatment of choice. Intravenous albumin is indicated for:

• anuria

• hypotension

• poor skin perfusion with skin mottling

• poor capillary return.

These are all indicators of a depleted vascular space. Albumin should be given only in consultation with the treating consultant. The dose is 20% albumin 5 ml/kg weight(1 g/kg weight) over 4 hr i.v. Beware of the possibility of hypertension and pulmonary edema. Gross genital edema causing discomfort may also be an indication for albumin.

b. Furosemide

Furosemide (1 mg/kg weight i.v.) should be given only if the peripheral perfusion markedly improves following the albumin or there are signs of pulmonary edema or hypertension.

c. Steroids

Corticosteroids are usually given in the form of prednisolone. Occasionally their use may be delayed until postrenal biopsy at the discretion of the treating physician. The usual dose of prednisolone is 60 mg/m² per day as single dose up to a maximum of 80 mg per day until remission of proteinuria (to trace or negative on urinalysis) for 4 days, then in reducing doses. There are various regimens for dose reduction. One example is:

•  prednisolone 45 mg/m² per day for 8 days then

• 60 mg/m² per alternate day for 8 days (four doses) then

• 45 mg/m² per alternate day for 8 days then

• 30 mg/m² per alternate day for 8 days then

• Reduce by 5 mg every 8 days until finished

d. Antibiotics

The altered immune system in patients with nephrotic syndrome is responsible for their enhanced risk of infection. Oral penicillin 12.5 mg/kg weight per dose b.d. is effective prophylaxis during the edematous phase. If the child is profoundly ill or appears to have sepsis, give cefotaxime 50 mg/kg weight per dose 6 hourly to a maximum of 2 g per dose (to cover Streptococcus pneumoniae, Hemophilus influenzae and Escherichia coli).

e. Anticoagulants

Renal, femoral, cerebral and pulmonary thrombosis can occur in nephrotic patients owing to hypovolemia, high platelet counts and loss of antithrombin III. Thus low-dose aspirin (10 mg/kg weight alternate days) is recommended in edematous nephrotic patients.

General measures

Other general measures include:

• Free fluid intake

• Diet with no added salt

• Strict fluid balance

• Daily weight

Relapses

Over 75% of patients will experience at least one relapse. A relapse is defined as proteinuria ++++ or +++ for 4 days. Management should be discussed with a physician. Prednisolone 60 mg/m² per day should be given until the urine is protein-free for 3 days and then the dose should be slowly reduced as above. If edema is absent, these relapses may not require penicillin and aspirin. Infrequent relapses (less than two relapses within a 6-month period) can be managed in the manner outlined above.

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Urinary Tract Infection (UTI) in Pediatric

The urinary tract is a common site of infection in children. The annual incidence is up to 1% in girls, but less common in boys. Radiological abnormalities are present in about 40% of children with UTIs, the most common being reflux. Asymptomatic bacteriuria in schoolgirls is about 1–2%. It is often difficult to diagnose a UTI on history or examination alone in children and a high index of suspicion must be held. The consequences of missing a UTI in a child with even minor urinary tract abnormalities may be significant.

Positive dipstick for leucocytes and nitrites in a sick child does not exclude another site of serious infection (e.g. meningitis). Organisms may also spread from the urinary tract to elsewhere including the meninges. Therefore further investigations as part of a septic work-up (e.g. LP) should not be omitted in a sick child who returns a positive dipstick.

Source pict: http://www.tipdisease.com/2013/12/urinary-tract-infection-in-children.html

History

Symptoms of serious urinary infections are often non-specific and include fever, irritability, poor feeding and vomiting. More specific features may include loin or abdominal pain, frequency and dysuria. These localising signs are often absent in younger patients. Some children with UTIs may look quite well, while others may appear very unwell.

Examination

This is often normal other than the presence of fever. Loin or suprapubic tenderness may be present. Urinary dipstick testing is only a screening test for a UTI. It has poor sensitivity and specificity (see below).

Initial investigations

A UTI cannot be diagnosed on symptoms alone, nor by culture of urine from a bag specimen. A definitive diagnosis can only be made by culture of urine obtained in a sterile fashion from a mid-stream urine (MSU), suprapubic aspiration (SPA), or a catheter specimen of urine (CSU). Prior antibiotic therapy may lead to negative urine culture in patients with UTI. The laboratory will test for antibacterial activity in the urine. Any child who is unwell or is under 6 months old should also have blood culture and electrolytes tested and should be considered for lumbar puncture.

a. Dipstick urine tests

Dipsticks can detect urinary protein, blood, nitrites (produced by bacterial reduction of urinary nitrate), and leucocyte esterase (an enzyme present in white blood cells). They are a screening test only. If you really suspect UTI you must send a specimen for microscopy and culture. Blood and protein are unreliable markers of UTI. Not all organisms produce nitrites and nitrites take time to develop in urine and so have poor sensitivity. Nitrites may appear in the urine in the presence of infections in other body systems.

Not all patients with UTI have pyuria. Leucocyte esterase can only be detected with relatively high WBC counts in urine, so the test has low sensitivity. Leucocytes from local sources (vagina, foreskin) may contaminate urine. Leucocytes appear in the urine in many other febrile illnesses, e.g. upper respiratory tract infection, pneumonia, etc. So the specificity is low. Overall combined sensitivity for both nitrites and leucocytes is around 50%, i.e. dipsticks may miss 50% of infections.

b. Urine specimen collection

There are several ways to collect urine specimens in children, each with its benefits and problems. Practice differs around the world. In the UK, SPA is the method of choice in

infants if a clean catch specimen is not possible. However, in North America, SPA is rarely practised. Parents are offered a choice between awaiting bag screening, confirmed

by CSU on positive specimens, or immediate catheterisation. 

- Urine bag. A urine bag is useful for collecting urine for screening purposes in children who cannot void on request (approximately 0–3 years). The genitalia should be washed with water and dried before application of the bag. Urine is tested with a dipstick for leucocytes and nitrites. If it is positive for either, you should obtain a definitive specimen by SPA (or CSU if SPA fails). If clinical suspicion is high, send a definitive specimen for culture regardless of the dipstick result. A negative dipstick result does not exclude a UTI. Do not send bag specimens for culture in acute presentations. Antibiotics should not be given unless a definitive urine specimen has been obtained.

- Suprapubic aspiration (SPA). SPA remains the preferred method in the UK to collect a minimally contaminated specimen. It should be considered in children too young to obtain an MSU, and with a high probability of UTI, or who are unwell and who warrant a more invasive investigation. The child should be offered fluid to drink. Bedside ultrasound equipment, if available, can improve the success rate of SPA by detecting a full bladder. One author reports 60% success collection rate of SPA and this increases to 80% if bladder ultrasound is used. The specimen should be screened with a dipstick and then sent for culture. Any growth from SPA urine usually indicates infection (but note possible contamination by skin commensals and fecal flora may occasionally produce a mixed growth).

- Catheter specimens. These are useful if SPA fails. The first few drops of the specimen should be discarded and the remaining specimen should always be sent for culture. Any growth of over 103 organisms per ml indicates infection. 

- Mid-stream urine (MSU). A mid-stream urine can be obtained from children who can void on request. The genitalia should be washed with water and dried before the specimen is taken. The first few millilitres should be voided and not collected and then a specimen is obtained. A pure growth of over 108 organisms per ml indicates infection. Apure growth of over 105 organisms per ml may indicate early infection and requires a repeat 

Treatment of UTI

Antibiotics may be given orally or intravenously for a UTI. Oral medication is appropriate for those over the age of 6 months who are not systemically unwell. Cotrimoxazole (200/40 mg in 5 ml) 0.3 ml/ Kg weight b.d. orally for 1 week is a suitable antibiotic. Alternatives include cephalexin 15 mg kg−1 (500 mg) orally three times a day. Any child who is unwell, and most children under 6 months, should be admitted for i.v. antibiotics. Treatment options vary around the world but suitable regimens include cefuroxime 50 mg/Kg weight per dose (maximum 2g) or gentamicin 7.5 mg/Kg weight (maximum dose 240 mg) i.v. daily and benzylpenicillin 50 mg/Kg weight (maximum dose 3 g) i.v. 6 hourly for children over 1 month of age. Gentamicin levels should be taken to ensure appropriate time between subsequent doses. All children should have antibiotic sensitivities checked at 24–48 hours and therapy adjusted accordingly. For children who are still in nappies a prophylactic dose of antibiotic, e.g. co-trimoxazole (200/40 mg in 5 ml) 0.15 ml/Kg weight in a single daily dose, or nitrofurantoin 3 mg/Kg weight at night should be maintained until the child is seen for follow up. If the child is not settling, repeat the urine culture to determine eradication of organism. A shocked child will require fluid resuscitation. Any child with underlying urinary  tract abnormalities should be discussed with the registrar or consultant.

Follow up investigations

All children with proven UTI should be referred for follow up in the general pediatric clinic, or by the child’s own pediatrician. All those with their first UTI should have a renal ultrasound. A micturating cysto-urethrogram (MCU), abdominal X-ray and DMSA (dimercapto-succinoacetic acid) scan may be necessary, but the decision needs to be considered on an individual basis. They are usually done in children under 1 year of age, and may be necessary for older children according to circumstances. For older children, discussion of the need for MCU should be deferred to the outpatient follow up visit. 

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