Edema, Pediatric

Basics

Description

Presence of abnormal amount of fluid in the interstitial spaces of the body; usually secondary to low albumin, obstruction of venous or lymphatic channels, or trauma �

Diagnosis

Differential Diagnosis

Localized
- Trauma: pressure or sun damage
- Infection
- Allergy
- Lymphatic obstruction (less common)
  - Filariasis
  - Radiation therapy
- Bee stings or insect bites
- Sickle cell dactylitis
Generalized
- Congenital: lymphatic obstruction of legs or thoracic duct
- Infection: hepatitis and liver failure; pericarditis
- Toxic, environmental, drugs
  - Sodium poisoning
  - Toxic effect on liver and/or heart (chemotherapy)
  - Cirrhosis
  - Drug reaction
- Tumor
  - Obstruction of venous return from enlarged abdominal lymph nodes or tumor
- Allergic/inflammatory: protein-losing enteropathy
- Renal
  - Nephrotic syndrome
  - Renal failure
  - Acute glomerulonephritis
- Cardiac
  - Congestive heart failure (CHF)
  - Pericarditis
- GI
  - Intestinal protein loss
  - Postpericardiotomy or congenital heart surgery
  - Hepatobiliary disease
- Endocrine: hypothyroidism

Etiology

Excessive losses of protein
- Renal losses
- GI losses
Inadequate production of protein
- Liver disease
- Malnutrition
Local trauma
Increased hydrostatic pressure
- CHF
- Cirrhosis
- Pericardial effusion
- Post-cardiac surgery
- Venous obstruction
  - Superior vena cava syndrome
  - Deep vein thrombosis
Lymphatic obstruction

Approach to the Patient

Determine the cause of swelling: Is it localized? Are there any sources of protein loss? Is there underproduction of protein? �

Phase 1: Is the swelling localized as seen in trauma, lymphatic, or venous obstruction?
Phase 2: Are there urinary or GI losses?
- Associated with decreased serum albumin
- Most likely source of loss is renal disease, less frequently GI losses
Phase 3: Search for other causes of edema, such as CHF, cirrhosis, lymphatic obstruction

History

Question: Is the edema localized or generalized?
Significance: See "Differential Diagnosis"�
Question: Is the patient asymptomatic or in some distress specifically because of the edema?
Significance: Determine treatment urgency
Question: Evidence of cardiac, renal, or GI disease?
Significance: Major causes of edema
Question: Waist size has become larger, difficulty putting shoes on, clothes too tight?
Significance: Evidence of edema in body
Question: Excess salt intake in diet?
Significance: In some patients, contributes to edema
Question: Shortness of breath?
Significance: There may be ascites, which compresses the diaphragm, or pleural effusions.
Question: Chronic diarrhea?
Significance: Seen in protein-losing enteropathy or lymphatic obstruction
Question: Has a urinalysis been performed in the past?
Significance: May help date the onset of the problem
Question: Swelling around the eyes or face?
Significance: May suggest allergies but should also consider other causes of edema such as nephrotic syndrome.
Question: Anemia?
Significance: Seen in protein-losing enteropathy

Physical Exam

Finding: Lumbosacral area, pretibial, scrotum/labia?
Significance: Dependent edema
Finding: Percussion of chest?
Significance: Pleural effusion
Finding: Shifting dullness?
Significance: Early sign of ascites
Finding: Soft ear cartilage?
Significance: Common finding in nephrotic syndrome
Finding: Pitting edema?
Significance: Seen in cases of protein loss
Finding: Nonpitting edema?
Significance: May be caused by venous/lymphatic obstruction or salt poisoning.

Diagnostic Tests & Interpretation

Test: Dipstick urinalysis
Significance: If there is generalized edema with heavy proteinuria, this is suggestive of nephrotic syndrome.
Test: Serum albumin
Significance:
- Hypoalbuminemia in the setting of edema and proteinuria supports diagnosis of nephrotic syndrome.
- If there is generalized edema with no proteinuria but hypoalbuminemia, consider cardiac, GI, or hepatobiliary disease and direct additional studies to evaluate these 3 organ systems specifically.
- If there is either localized edema or generalized edema but a normal urinalysis and a normal serum albumin, consider other unusual causes for edema, such as mechanical or lymphatic obstruction, certain endocrine disorders, or the effects of drugs or toxins.
Test: Alpha-1-antitrypsin in stool
- Significance: Seen in protein-losing enteropathy
Test: Cholesterol
- Significance: Only high in hypoalbuminemia associated with nephrotic syndrome

Treatment

Additional Treatment

General Measures

Moisturize skin.
Avoid pressure sores.
Decrease sodium intake.
Active or passive leg exercise to avoid venous thromboses.
If edema is massive, the patient may awaken with swollen eyelids. Place blocks under the head of the bed to keep the patient's head elevated.
If there is scrotal edema, jockey shorts will help support the scrotum and protect the skin from breaking down.
For severe edema with respiratory distress, severe abdominal discomfort, or severe scrotal edema, consider treatment with albumin and/or furosemide infusion.

Issues for Referral

Nephrotic syndrome-pediatric nephrologist
Protein-losing enteropathy or hepatobiliary disease-pediatric gastroenterologist
CHF-pediatric cardiologist
Endocrine-mediated edema-pediatric endocrinologist
Lymphatic or other mechanical obstructions-vascular surgeon or pediatric surgeon

Initial Stabilization
Any child or adolescent with an edema-forming state that compromises either cardiorespiratory function or the vascular integrity of a peripheral organ or limb should be referred immediately to an appropriate specialist for emergency care. �

Additional Reading

Braamskamp �MJAM, Dolman �KM, Tabbers �MM. Clinical practice. Protein-losing enteropathy in children. Eur J Pediatr. 2010;169(10):1179-1185. �[View Abstract]
Holliday �MA, Segar �WE. Reducing errors in fluid therapy management. Pediatrics. 2003;111(2):424-425. �[View Abstract]
Jacobs �ML, Rychik �J, Byrum �CJ, et al. Protein-losing enteropathy after Fontan operation: resolution after baffle fenestration. Ann Thorac Surg. 1996;61(1):206-208. �[View Abstract]
Molina �JF, Brown �RF, Gedalia �A, et al. Protein losing enteropathy as the initial manifestation of childhood systemic lupus erythematosus. J Rheumatol. 1996;23(7):1269-1271. �[View Abstract]
Moritz �ML, Ayus �JC. Prevention of hospital acquired hyponatremia: a case for using isotonic saline. Pediatrics. 2003;111(2):227-230. �[View Abstract]
Rosen �FS. Urticaria, angioedema, and anaphylaxis. Pediatr Rev. 1992;13(10):387-390. �[View Abstract]
Vande Walle �JG, Donckerwolcke �RA. Pathogenesis of edema formation in the nephrotic syndrome. Pediatr Nephrol. 2001;16(3):283-293. �[View Abstract]

Codes

ICD09

782.3 Edema
995.1 Angioneurotic edema, not elsewhere classified

ICD10

R60.9 Edema, unspecified
R60.0 Localized edema
R60.1 Generalized edema
T78.3XXA Angioneurotic edema, initial encounter

SNOMED

267038008 edema (finding)
274724004 Localized edema (finding)
271808008 edema, generalized (finding)
402387002 allergic angioedema (disorder)

FAQ

Q: At what level of serum albumin does edema occur?
A: Edema is generally associated with serum albumin <2.5 g/dL.
Q: Why does pericardial effusion cause edema?
A: Pericardial effusion is associated with decreased lymphatic flow and increased venous pressure.

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