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It’s early evening and, for once, volume is reasonable. You get the overhead page that a transfer call is waiting for you on the phone. You take the call, hoping beyond all hope that it won’t end your peaceful evening. It’s a private pediatrician in a rural region of the state. He’s about two counties away from your medical center but refers a lot of specialty patients because his local resources are somewhat limited, especially for kids. This time he’s referring because he wants input from the child abuse team.

He’s not sure this is abuse, mind you. He has a six-year-old girl in his office. Her parents brought her in to see him because they noticed blood on her underwear at bath time. They looked and saw that she seemed to have vaginal bleeding. The child denies that anyone has “messed” with her. She’s been followed by this physician since infancy and he’s never had any concerns about her safety. He has examined her carefully and is convinced that the bleeding is coming from the vagina. You accept the transfer and await arrival.

When the child arrives some time later she is a friendly and engaging. She looks clean and well cared for and her interactions with her parents seem appropriate. Interviewing her by herself, with the parents out of the room, she does not report anyone touching her down there. In fact, she denies any symptoms at all. With her parents back in the room, you ascertain that she has no significant medical history. She attends public school and then comes home afterwards. They don’t know anyone to suspect of abuse, although that is their chief concern.

You hand the mother a gown to get her child ready to be examined. As you wait, you review the possible sources of vaginal bleeding in a six-year-old girl.

First of all, is it vaginal? A common cause of apparent vaginal bleeding is urethral prolapse. It can be diagnosed by its characteristic doughnut-shaped mass at the urethral opening, which can be large enough to obscure the vaginal opening and make the bleeding appear to be vaginal in origin. Trauma to the vulva or urethra can cause bleeding, but you’d like some supporting history. Genital warts can cause bleeding but you’d think the referring MD would have noticed those. Inflammation of the skin from rashes can bleed. Some kids with pinworms scratch hard enough to bleed. Bleeding could be from the urine, such as a hemorrhagic cystitis or renal abnormality. Or maybe this is rectal bleeding.
So, what if the bleeding is vaginal. Is the child pre-pubertal? A six year old should be, but you need to look carefully for evidence of precocious puberty, such as breast development, axillary and pubic hair. If she is pre-pubertal, then your differential is narrowed. It could still be trauma, including child abuse. Vaginal infection, such as group A strep, shigella (which can occur without diarrhea), candida or gonorrhea can cause this. Vaginal foreign body is on your list, as is (although very rare!) a tumor.
Because sexual abuse is in the differential, you call the Sexual Abuse Nurse Examiner (SANE) to go in with you for the exam. That way, if there are findings to be documented, you don’t put the child through the genital exam twice. Since the child has no objection, you also have the parents in the room while you perform the exam, so you can point out any findings to them.

You proceed in your usual fashion, with a head-to-toe check-up. This way, you can uncover any relevant findings beyond the genitalia, such as determining pubertal status and looking for any other evidence of trauma. You also “normalize” the genital exam by smoothly incorporating it into the kind of check-up that is more routine for the child. 

The examination reveals a pre-pubertal healthy six year-old. There are no findings on the rest of her examination. A urine she provided appears yellow and dips negative for blood. The external genital exam, done in frog-leg and knee-chest position, is also completely normal.

So now what do you think? At this point, the most likely item left on your differential is foreign body. The child denies putting anything up there, but one of the most common culprits is a wad of toilet paper. You have made the child NPO as the exam often requires sedation in pre-pubertal children. You consult Gyn and they come down to see her. She is so cooperative that they are able to gently explore her and do a little careful saline lavage, which causes her to expel the wad of somewhat bloody toilet paper that caused the whole problem.

The parents are happy that it wasn’t a case of sexual abuse. The referring physician, when you call him, is happy that it wasn’t a case of sexual abuse. And you got to do a little medical detective work. Good job Sherlock. It continues to be a nice evening in the Pediatric ED.     
 
Continue Next for Dr. Levine's Tip of the Month 
{mospagebreak=title Tip of the Month}
 
Codeine for a breast-feeding mother
 
Most physicians who treat pregnant patients are very aware that they are potentially dealing with two patients, the mother and her unborn baby. But don’t forget, after the baby is born, if the mother is breast feeding, the baby still needs to be taken into account. Recently, a 13-day-old breast feeding infant died whose mother had been prescribed codeine for episiotomy pain. The mother was not taking a large dose but it turns out that she had a genetic variant causing her to rapidly metabolize the codeine, leading to abnormally high morphine levels in her milk. The FDA reviewed the case and advised caution on the use of codeine or other narcotic medications to nursing mothers. So what should you do? Prescribe the lowest dose you can for the shortest period possible. Make sure the mother knows the potential risk. Have her watch her infant for sleepiness, poor feeding, lethargy, hypotonia, or breathing difficulties and come to the ED at once if these occur.  

 

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