Pediatric emergency medicine trisk 0555 0555
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with anaphylaxis, this edema may involve the tissues adjacent to the airway
leading to potential airway compromise.
When intravascular albumin levels are within the normal range and vascular
permeability is preserved, edema can result from increased hydrostatic pressures
that overcome the oncotic pressure, forcing fluid out of the vascular space. This
can occur as a result of changes in sodium and water retention from cardiac
failure, renal failure or estrogen–progesterone excess, or from venous obstruction.
Lymphatic dysfunction, either congenital or acquired, can also result in edema.
DIFFERENTIAL DIAGNOSIS
A myriad of disease processes can result in either localized or generalized edema
( Table 25.1 ). Localized edema in children is often caused by an allergic
reaction, with the most severe reactions resulting from exposure to nuts, shellfish,
or hymenoptera venom. Idiopathic nephrotic syndrome, although rare (occurring
in 4.7 of every 100,000 children annually), is the most common cause of
generalized edema ( Table 25.2 ). Overall, most children who develop edema will
have a benign diagnosis and a self-limited course. However, potentially lifethreatening conditions ( Table 25.3 ) causing edema can also occur, including
severe allergic reactions, sepsis, venous thrombosis, and kidney, liver, or cardiac
disease.
EVALUATION
When evaluating the child with edema it is necessary to obtain a thorough history
and perform a complete physical examination, including the assessment of vital
signs. It is important to remember that the onset of symptoms is often gradual and
subtle for causes of generalized edema. In fact, significant weight gain may be
accumulated, with symptoms existing for weeks to months, before a patient
presents for medical care. It is, therefore, essential to inspect for edema around
the eyes, scrotum or labia, as well as the distal extremities, as these areas may be
the only locations with perceptible swelling.
It is also helpful to classify the swelling as localized or generalized ( Fig. 25.1 )
and to determine the location of the edema (facial vs. extremities), as well as any
associated symptoms including fever, shortness of breath, pain, or recent illness.
The duration of the symptoms and the patient’s age may help to narrow down the
potential diagnoses, as certain disorders will present in the newborn period
(congenital lymphedema, Turner syndrome) while others occur more frequently
in school-age children or adolescents (nephrotic syndrome, vasculitis). A
thorough medical history, including a dietary history and a family history, is
helpful to identify patients with chronic conditions, such as protein malnutrition,
