Approach to a Child with Edema

Before beginning the clinical approach to a child with edema, it is necessary to understand the basics of fluid compartments, starling forces and technique of eliciting edema.

Life threatening causes of Edema:

Generalized:

1. Cardiac disease
   • Congestive Heart Failure
   • Pericardial effusion
2. Renal disease
   • Nephrosis
   • Nephritis
3. Hepatic failure

Localized:

1. Allergic reaction with airway involvement
2. ACE inhibitor induced angioedema
3. Cellulitis
4. Group A Streptococcus with Varicella
5. Snake bite
6. Thrombophlebitis

APPROACH TO LOCALIZED EDEMA:

1. Common causes:

Fever	Local tenderness	Local warmth	Lesion/color
Allergic reaction	No	No	Yes	Erythematous
Trauma	No	Yes	No	Violaceous
Infection	Usually	Yes	Yes	Erythematous or Violaceous

A therapeutic response to an oral antihistamine or an intramuscular dose of epinephrine can help to differentiate an allergic reaction from other causes.

2. Other Aids to Diagnosis:

• Bilateral upper eyelid edema: Infectious mononucleosis (Hoagland’s sign)
• Severe or recurrent facial edema with positive family history: Hereditary angioedema
• Acute facial edema with cyanosis or plethora: SVC obstruction
• Other causes of facial edema: Oral, dental or sinus infections
• History of environmental exposure: Sunburn, frost-bite, plant-induced dermatitis
• Infant with unexplained localized swelling of extremity since birth:
  • Birth trauma
  • Congenital lymphedema (Milroy’s disease)
  • Turner’s syndrome (Bilateral limb edema)
  • Noonan’s syndrome (Pedal edema)
• Swollen and painful digits (dactylitis): Sickle cell anemia
• Weightlifting, OCPs: Thrombophlebitis or DVT

APPROACH TO GENERALIZED EDEMA

A. History:

Components	Significance
Age of onset	Newbornvs Older children
Mode of onset	Sudden (<72 hrs)- Acute Nephritis, Allergic reaction
Site and evolution	Legs → Face → Ascites (Cardiac)Ascites → Legs → Face (Hepatic) Face → Legs → Ascites (Renal) Acute edema of face and neck – SVC obstruction
Timing	Increase in morning – HypoproteinemiaIncrease in evening – Congestive cardiac failure
Exposure	Medications,Danders, Food preservatives – Allergic reaction
Nutritional history	Low protein intake – PEM
Past/Allergic history	Sore throat and joint pain – Rheumatic carditis Neonatal umbilical vein sepsis or Umbilical vein catheterization – Hepatic cause Chronic illnesses, Persistent diarrhea – PEMMilk allergy, Gluten sensitivity – Protein losingenteropathy

Associated symptoms	Significance
Orthopena, PND, Noisy breathing, Poor weight gain, Feeding difficulties, Bluish episodes	Cardiac cause
Yellowish discoloration, Dark urine, Black tarry stool, Pain/lump in abdomen, Itching, Petechiae	Hepatic cause
Rashes, joint pain	Connective tissue disorders
Nausea, vomiting, retarded growth	Uremia
Frothy urine	Nephrotic syndrome
Blood in urine, decreased urine	Nephritic syndrome
Anorexia, lethargy, diarrhea, vomiting, decreased growth, frequent infections, night blindness	Malnutrition
Cow milk intake, foul diarrhea, recurrent abdominal pain, frequent infections	Protein losing enteropathy

B. General Physical Examination

Findings	Significance
Tachycardia, Prolonged CRT	Cardiac diseases
Hypertension	Acute Nephritic Syndrome
Tachypnea	Pulmonary edema
Raised JVP	Congestive cardiac failure
Altered consciousness Disoriented	Hepatic Encephalopathy Hypertensive Encephalopathy (Renal)
Asterixis	Hepatic encephalopathy
Pallor	Anemia, Malnutrition
Icterus, spider angioma, other stigmata	Chronic Hepatic diseases
Cyanosis and clubbing	Congenital Heart Disease
Flag sign, Bitot’s spot, Stomatitis, Muscle wasting, Dehydration, Hypothermia	Malnutrition
Abnormal anthropometry	Malnutrition

C. Systemic Examination – Diagnostic Aids

1. Gallop, Tachycardia, Tachypnea, Inspiratory crackles or Hepatomegaly: Cardiac disease
2. Pericardial rub, Pulsusparadoxus, Muffled heart sounds, Jugular venous distension: Pericardial effusion
3. Hepatosplenomegaly and Ascites: Hepatic cause (If no icterus – exclude portal vein thrombosis)
4. Hepatomegaly (fatty liver): Malnutrition

GENERAL INVESTIGATIONS

1. Urine dipstick and microscopy:
   • Proteinuria, casts and hematuria are indicative of renal disease
2. Renal function test and electrolytes:
   • Raised serum urea and creatinine are indicative of renal disease
   • Hyperkalemia, Hypokalemia, Hyperphosphatemia, Hypocalcemia
3. Full Blood Count and Peripheral Blood Smear

• normochromic normocytic anaemia suggest chronic disease
• hypochromic microcytic anaemia suggest iron deficiency from occult gastrointestinal bleeding i.e. cows milk allergy
• megaloblastic anaemia suggest vitamin B12 and folate deficiency from small bowel disease
• eosinophilia suggest angioedema or protein losing enteropathy

1. Liver function test (LFT)
   • Hypoalbuminaemia in the absence of circulatory overload suggests hypoproteinaemic states
   • Hyperbilirubinaemia and transaminitis suggest liver disease
2. Chest X-ray and electrocardiogram
   • Cardiomegaly with prominent perihilar vascular marking and left ventricular hypertrophy confirms intravascular fluid overload
   • ST elevation with t wave inversion (Pericarditis)
   • ECG can provide clue to other causes of heart failure

SPECIFIC INVESTIGATIONS

Depending upon the most likely cause

1. Cardiac cause: Echocardiography
2. Nephrotic syndrome: 24 hour urine protein, Urine protein to creatinine ration, Fasting lipids, Screen for secondary causes e.g. SLE, Hepatitis B
3. Nephritic syndrome: Serum complements, Screen for secondary causes e.g. Streptococcal infection, SLE, IgA nephropathy
4. Chronic Liver Disease: Screen for underlying cause, Assess complication e.g. Hyperammonemia, Coagulopathy
5. Cow’s milk allergy: FAST test for cow milk IgE, Patch test, Jejunal biopsy
6. Gluten hypersensitivity: Anti-gliadinIgG/IgA, Anti-endomysialIgA, Jejunal biopsy
7. Malnutirtion: Blood glucose, Septic screening, Stool & urine for parasites & germs, Electrolytes, Ca, Ph & ALP, serum proteins, CXR & Mantoux test, Exclude HIV & malabsorption

PRINCIPLE OF TREATMENT

1. First principle: Reversing the primary disease
2. Second principle: Restore hemodynamics and cardiac output

TREATMENT OF LOCALIZED EDEMA

1. Insect bite reaction:
   • Anti-histamine
   • Anti-inflammatory (topical corticosteroid)
2. Local infection:
   • Incision and drainage
   • Wound dressing
   • Antibiotics

TREATMENT OF GENERALIZED EDEMA

Supportive:

1. Bed rest

• Decrease peripheral pooling
• Augment blood volume in central circulation
• Increases cardiac output, renal and hepatic perfusion
• Increases sodium diuresis

2. Sodium restriction

• 1-1.5 mEq/kg/day
• Avoid salty foods

3. Water balance

• Daily intake = Urinary loss + Insensible water loss
• When diuresis occurs, avoid water restriction

Diuretic therapy:

1. Loop diuretics (Furosemide/Lasix)

• 1-2 mg/kg/day (IV/IM/PO)
• Note: higher doses are required in acute glomerulonephritis or chronic renal impairment
• Side effects- hyponatremia, hypokalemia, metabolic alkalosis

2. Hydrochlorothiazide

• In steroid resistant Nephrotic syndrome
• 0.5-2 mg/kg/day P.O.

3. Spironolactone

• Initial therapy in edema of liver cirrhosis
• 1 to 3 mg/kg/day P.O.

Specific treatment:

1. Nephrotic syndrome:

• Prednisolone
  • 1st 6 weeks: 2mg/kg/day on daily basis
  • Next 6 weeks: 1.5 mg/kg/day; morning dose on alternate days
• Nephrotic diet
• IV albumin (sodium poor; slow infusion) with diuretics for severe oedema
• Steroid sparing agents in steroid dependent/resistant cases

2. Acute Glomerulonephritis:

• Diuretics (first line)
• I.V. Anti-hypertensives (Nifedipine, Diazoxide)
• Dialysis in severe cases
• Treat underlying cause

3. Chronic liver disease:

• IV albumin with diuretics for severe oedema
• Liver failure management

4. Cardiac failure:

• Diuretics
• Salt and fluid restriction
• Digoxin
• Treat arrhythmias

5. Cow’s milk allergy:

• Avoid cow’s milk
• Consider soy based formula
• Treat iron deficiency

6. Gluten hypersensitivity:

• Gluten free diet
• Treat iron deficiency

7. Malnutrition:

SUMMARY

1. Localized edema is commoner than Generalized
2. Commonest cause of edema in children:
   • Generalized: Idiopathic nephrotic syndrome
   • Localized: Allergic reaction
3. Most children will have a benign diagnosis and self-limited course
4. General measures for treatment include management of primary disease, bed rest, Na+ restriction and Diuretic administration.
5. Most reliable index of progression of treatment of edema is daily alteration of body weight.

CONTRIBUTORS

2nd Batch, KIST Medical College

Shraddha Shrestha
Shuveccha Pandey
Srijana Shakya
Sulabh Shrestha
Surakshya Raymajhi