What is the appropriate management for a 2‑year‑old child with splenic infarction?

Management of Splenic Infarction in a 2-Year-Old Child

Conservative management with supportive care is the appropriate approach for a 2-year-old with splenic infarction, reserving splenectomy only for life-threatening complications such as splenic rupture, abscess formation, or persistent hemorrhage. 1

Initial Assessment and Stabilization

Determine hemodynamic stability first, as this dictates the entire management pathway:

• Assess for systolic blood pressure appropriate for age, absence of skin vasoconstriction, normal consciousness, and no respiratory distress 2
• In a hemodynamically stable 2-year-old, proceed with conservative management 1
• If hemodynamically unstable, immediate operative intervention is mandatory 2

Diagnostic Confirmation

CT scan with intravenous contrast is the gold standard for diagnosing splenic infarction, with 90-95% sensitivity and specificity 1:

• Infarcts appear as peripheral, wedge-shaped, low-density areas 1
• MRI offers similar diagnostic accuracy if CT is contraindicated 1
• Ultrasound is less sensitive but may be used; Doppler should be added to evaluate splenic vascularization 1
• Avoid nuclear medicine scans as they are obsolete and provide no diagnostic value 1

Conservative Management Protocol

Implement clinical and laboratory observation with bed rest for the first 48-72 hours 1:

• Monitor hemodynamic stability with frequent vital signs 1
• Perform serial hematocrit measurements to detect ongoing bleeding 1
• Provide supportive care including hydration and analgesia 3
• Most uncomplicated infarctions resolve within 7-14 days 3

Watch vigilantly for complications that would change management:

• Persistent or recurrent fever suggesting abscess formation 1
• Recurrent bacteremia or ongoing sepsis 1
• Persistent abdominal pain or signs of peritonitis 1
• Hemodynamic instability or significant drop in hematocrit 1

Special Considerations for Pediatric Patients

Consider underlying etiology specific to this age group:

• In children under 5 years with sickle cell disease, splenic sequestration is a critical differential that requires prompt recognition and careful red blood cell transfusion (3-5 mg/kg aliquots) to avoid overtransfusion 4
• Hematologic disorders are more common causes in patients under 40 years old 3
• If sickle cell disease is the underlying cause, chronic transfusions to reduce hemoglobin S to <30% may be needed 1

Indications for Surgical Intervention

Splenectomy is absolutely indicated for:

• Splenic abscess formation that responds poorly to antibiotics alone 1
• Splenic rupture with hemorrhage and hemodynamic instability 1
• Failed non-operative management with continued hemodynamic instability or significant drop in hematocrit requiring continuous transfusions 1

Percutaneous drainage may be considered for splenic abscesses in high-risk surgical candidates who cannot tolerate splenectomy 1

Monitoring and Follow-Up

Serial imaging may be warranted:

• Ultrasound or contrast-enhanced ultrasound follow-up is reasonable to minimize risk of life-threatening hemorrhage 1
• Repeat imaging is indicated if there is decreasing hematocrit, persistent fever, or clinical deterioration 2
• Most infarcts improve clinically and radiographically with appropriate treatment of the underlying cause 1

Activity restriction after resolution:

• Resume normal activity after at least 6 weeks for moderate-severe injuries 4, 2
• Shorter restrictions may be appropriate for minor infarctions 4

Critical Pitfalls to Avoid

• Do not rely on clinical splenomegaly as a reliable indicator of infarction severity, as it is present in only 30% of cases 1
• Do not rush to splenectomy in hemodynamically stable patients, as the vast majority of pediatric splenic pathology can be managed conservatively with success rates of 95-100% 4
• Do not miss splenic sequestration in young children with sickle cell disease, which requires different management than simple infarction 4
• Do not discharge without ensuring differentiation between uncomplicated infarction and abscess, which is made based on clinical and radiographic improvement 1