Figure 126-2 Initial management of gastrointestinal bleeding. CBC, Complete blood count; FFP, fresh frozen plasma; NG, nasogastric; PRBCs, packed red blood cells; PT, prothrombin time; PTT, partial thromboplastin time.
and no resuscitation is required. For children with large-volume bleeds, the ABCs of resuscitation (airway, breathing, circulation) should be addressed first (see Chapters 38 and 40).Oxygen should be administered and the airway protected with an endotracheal tube if massive hematemesis is present.
Fluid boluses and transfusion with packed red blood cells as required should be administered through two large-bore IVs. Frequent reassessment should continue to ensure maintenance of physiological stability (Fig. 126-2).
Medications taken for a variety of conditions may cause oral abnormalities. Drugs with anticholinergic properties diminish saliva production and increase the risk of dental caries and parotitis. Tetracyclines taken before the eruption of the permanent teeth stain the enamel. Excessive fluoride in vitamin preparations or in drinking water can result in mottled teeth. Gingival hypertrophy may be caused by cyclosporine, phenytoin, and calcium channel blockers.
Gastroesophageal reflux disease (GER) can lead to substantial enamel erosion and caries. Neonatal hyperbilirubinemia can result in bluish discoloration of the deciduous teeth. Renal failure is associated with mottled enamel of the permanent teeth. Congenital syphilis causes marked abnormalitiesin the shape of teeth, especially incisors and molars. Celiacdisease can result in enamel defects. Crohn’s disease is associated with oral aphthous ulcers. Abnormal pigmentation ofthe lips and buccal mucosa is seen with Peutz-Jeghers syndrome and Addison disease. Candidiasis is seen commonlywith immunodeficiency disorders and diabetes. Leukemicinfiltrates result in gum hyperplasia and bleeding; treatmentof neoplastic conditions can cause severe mucositis. Sometumors, including lymphoma, may present as mass lesions ofthe buccal cavity.
Osteogenesis imperfecta is associated with abnormal dentin and risk of caries. Children with ectodermal dysplasiascommonly have malformed or missing teeth. Pierre Robin syndrome is associated with micrognathia and cleft palate. Disorders resulting in facial dysmorphism can have a profound effect on dental occlusion and mandibular function. Examples include mandibulofacial dysostosis, Crouzon syndrome, conditions associated with dwarfism, and others.
Most infants are born without teeth. Natal teeth are present at birth, are usually supernumerary, and may be poorly attached. Usually, no treatment is necessary, but removal by a dentist may be needed if they are causing difficulties with feeding or injuries to the tongue. Table 127-1 presents the ages when normal deciduous teeth are acquired. The lower central incisors are typically the first to erupt, followed by the upper central incisors, lateral incisors, first molars, and bicuspids. Delayed eruption may occur in association with hypopituitarism, hypothyroidism, osteopetrosis, Gaucher disease, Down syndrome, cleidocranial dysplasia, and rickets. Deciduous teeth begin to be replaced by the permanent teeth at around age 6
PRIMARY, AGE (mo) PERMANENT, AGE (yr) years. The sequence of replacement is similar to that of the appearance of deciduous teeth.