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Addendum: Pediatrics Review

Addendum: Pediatrics Review. WHO 2009 Classification. Dengue without warning signs: Live in/travel to endemic areas Fever and 2 of the ff criteria: Nausea, vomiting Rash Aches & pains Tourniquet test positive Leukopenia. WHO 2009 Classification. Dengue with warning signs:

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Addendum: Pediatrics Review

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  1. Addendum: Pediatrics Review

  2. WHO 2009 Classification • Dengue without warning signs: • Live in/travel to endemic areas • Fever and 2 of the ff criteria: • Nausea, vomiting • Rash • Aches & pains • Tourniquet test positive • Leukopenia

  3. WHO 2009 Classification • Dengue with warning signs: • Abdominal pain or tenderness • Persistent vomiting • Clinical fluid accumulation • Mucosal bleed • Lethargy, restlessness • Liver enlargement > 2 cms • Increase in hct with decrease in platelet

  4. WHO 2009 Classification • Severe dengue: • Severe plasma leakage • Shock (DSS) • Fluid accumulation with respiratory distress 2. Severe bleeding • As evaluated by clinician

  5. WHO 2009 Classification 3. Severe organ involvement • liver: AST or ALT >1,000 • CNS: impaired consciousness • Heart and other organs

  6. Dengue Fever • Dengue NS-1 Ag – Day 1 and Day 4 of the illness

  7. Rickets • Disease of growing bone which occurs in children only before fusion of the epiphyses • Due to unmineralized matrix at the growth • Increase in the circumference of the growth plate and the metaphyses --> widening of the wrists & ankles • General softening of the bones

  8. Rickets • Craniotabes or softening of the cranial bones • Widening of the costochondral junctions leads to “rachitic rosary” • “Harrison groove” is a horizontal depression along the lower anterior chest due to pulling of the softened ribs by the diaphragm during inspiration

  9. La Leche League International • All milk should be dated before storing. • Preferably, human milk should be refrigerated or chilled right after it is expressed. • Guidelines for storing human milk: • At room temperature (19-26 C) for 4 hours (ideal), up to 6 hours (acceptable) • In a ref < 4 C for 72 hrs (ideal), up to 8 days (acceptable)

  10. LLLI 3. In a freezer (-18- -20 C) for 6 months (ideal), up to 12 months (acceptable) . What type of container should be used? • Glass or hard-sided plastic containers with well-fitting tops • Containers not made with the controversial chemical bisphenol A (BPA) • Containers which have been washed in hot, soapy water, rinsed well, and air-dried

  11. LLLI 4. Containers should not be filled to the top - leave one inch of space to allow for expansion 5. Put only 2-4 ozs of milk in the container to reduce waste. 6. Disposable plastic bags are not recommended as it leads to greater risk of contamination.

  12. How to warm the milk: • Do not refreeze thawed milk. • Previously frozen milk that has been thawed can be kept in the refrigerator for up to 24 hrs. • Frozen milk: thaw in the ref overnight or under cool running water • Refrigerated milk: under warm running water for several minutes. Do not heat the milk directly on the stove. Do not use microwave.

  13. Guidelines on Infant & Young Child Feeding • UNICEF & WHO recommend that infants be exclusively breastfed on demand for the 1st 6 months of life • Early introduction of food & other liquids? • Reduces breast milk intake • Decreases full absorption of nutrients from breast milk • Increases the risk of diarrhea and URI

  14. Febrile Seizures Most common seizure disorder in childhood Rare before 9 months and after 5 yrs old Peak age of onset: 14-18 months old Normal neurologic exam Normal EEG (+) family history

  15. Simple: Lasts a few secs & rarely >15 mins. Initially generalized and tonic-clonic Followed by a brief period of post-ictal drowsiness Occurs only once in 24 hrs Complex: Duration is >15 mins. Repeated convulsions occur within 24 hrs Focal seizure activity Comparison:

  16. Status Epilepticus • One seizure lasting 30 mins or multiple seizures during 30 mins without regaining consciousness • Usual cause: breakthrough seizures - missed doses of anti-epileptic drug/s • May be due to CNS infection

  17. Persistent PulmonaryHypertension of the Newborn • Failure of the normal circulatory transition that occurs after birth • Syndrome: marked pulmonary hypertension that causes hypoxemia and right-to-left extrapulmonary shunting of blood • With inadequate pulmonary perfusion, neonates are at risk for developing refractory hypoxemia, respiratory distress, and acidosis.

  18. PPHN • Most common cause is meconium aspiration syndrome • about 13% of all live births are complicated by meconium-stained fluid but only 5% who had this complication subsequently develop MAS • Coarse streaking granular pattern in both lung fields • Irregularly aerated lungs • Flattened diaphragm, increased AP diameter

  19. PPHN • 2nd most common cause is idiopathic • “black-lung” • Significant remodeling of pulmonary vasculature with vascular wall thickening and smooth muscle hyperplasia • Contributory factor: use of NSAIDs during 3rd trimester leading to constriction of the fetal ductus arteriosus in utero

  20. SMR in Boys SMR Stage PUBIC HAIR PENIS TESTES 1 None Preadolescent Preadolescent • Scanty, long, slightly pigmented Slight enlargement Enlarged scrotum, pink, texture altered • Darker, starts to curl, small amount Longer Larger • Resembles adult type but less in quantity; coarse, curly Larger; glans and breadth increase in size Larger, scrotum dark • Adult distribution, spread to medial surface of thighs Adult size Adult size

  21. SMR in Girls

  22. Gross motor skills • 6 years old – skip • 8 years old – hop on one foot twice, then the other

  23. Fine motor skills • 6 years old- tie shoe laces • 7 years old- print letters, letter reversal • 8-10 years old– rapid alternating movement of the hand, cursive writing • 10-12 years old – manipulative abilities similar to adult

  24. Social development • Expanding social world • Identification and reliance on peer groups 7 years – attachment to parents decrease and to peers increase 9 years – tightly knit groups are formed; group loyalty and commitment to best friends

  25. Social development 4-5 y/o • Toilet-trained • Plays imaginary games • Helps in tasks in house • Cooperative group play: takes turns and shares • Tender and protective • Cooperative most of the time • Chooses own friends

  26. Emotional development4-5 yrs old • Make-believe games • Toy guns are simply an innocent and entertaining way to be competitive and to boost their self-esteem (Shelov, 1994). • Interest in basic sexuality • May play with their genitals ---- signs of normal curiosity! • Do not scold or punish! Be straightforward

  27. Emotional development:4-5 yrs old • Parents should answer in simple and correct terms. • Parents should tell their child not to let other person touch the “private parts”. • Teach your child not to talk to strangers. • Teach child’s name, address, phone if lost. • Normal for a 4 year old to make up stories. • Encourage child to sleep in own bed.

  28. APGAR Score • What is the order of disappearance in a sick baby? • Color • Respiration • Muscle tone • Reflex • Cardiac rate

  29. APGAR Score • What is the order of appearance in a resuscitated baby? • Cardiac rate • Color • Respiration • Reflex • Muscle tone

  30. Essential IntrapartumNewborn Care • Immediately after birth: dry the baby to stimulate breathing & to avoid hypothermia • Delay cord clamping 2-3 minutes after birth or until the cord has stopped pulsating (less occurrence of IVH and anemia in terms & preterms) ***clamp the cord without milking it 2 cms from the base & put the 2nd clamp 5 cms from the base and cut the cord

  31. Essential IntrapartumNewborn Care • Early skin-to-skin contact: place the baby on mother’s chest or abdomen • to provide warmth • to increase the duration of breastfeeding • to allow the “good bacteria” from the mother’s skin to infiltrate the newborn (prevents hypoglycemia)

  32. Essential Intrapartum Newborn Care • Washing should be delayed until after 6 hours of life because this removes the vernix, thus exposing the newborn to hypothermia. • Non-separation of mother and newborn for breastfeeding: 20-60 minutes after birth

  33. Newborn Care • Eye prophylaxis • Erythromycin ointment 0.5% or tetracycline ointment 1% • Vitamin K: 1 mg IM • Vaccine: Hepatitis B and BCG

  34. Newborn Screening Test • Congenital hypothyroidism • Congenital adrenal hyperplasia • Galactosemia • Glucose 6-phosphate dehydrogenase deficiency • Phenylketonuria

  35. Newborn Screening Test • RA #9288 • Done at 48 hours old • If blood was collected <24 hours old, repeat at 2 weeks old.

  36. Normal birth weight & length Delayed physical, mental & sexual development Sluggish, feeding difficulties, hypothermia Edema of scrotum / genitals Prolonged physiologic jaundice Congenital Hypothyroidism

  37. Deficiency of 21-hydroxylase enzyme: deficiency of cortisol Normal at birth but signs of sexual & somatic precocity appear within the 1st 6 months of life Vomiting, failure to thrive Congenital Adrenal Hyperplasia

  38. Galactosemia • 3 distinct enzyme deficiencies: • galactose-1-phosphate uridyltransferase deficiency (GALT) - classic form • Galactokinase deficiency (GALK) • Galactose-4-epimerase deficiency (GALE) • Injury to parenychymal cells of the kidneys, liver & brain • Feeding intolerance, vomiting, jaundice, convulsions, lethargy, hypotonia, mental retardation

  39. G6PD deficiency • Episodic or chronic hemolytic anemia • Episodic: symptoms develop 1-2 days after exposure to a substance with oxidant properties: • sulfonamides, nalidixic acid, nitrofurantoin, chloramphenicol, antimalarials, vitamin K analogs, ASA, benzene, naphthalene

  40. Onset of hemolysis results in precipitous fall in Hgb & Hct Heinz bodies Reticulocytosis Jaundice, anemia, hemolysis, acute renal failure G6PD deficiency

  41. Phenylketonuria • Deficiency of the enzyme phenylalanine hydroxylase causes accumulation of pheynylalanine in body fluids (hyperphenylalaninemia) • Excess phenylalanine is transaminated to phenylpyruvic acid or decarboxylated to phenylethylamine & disrupts normal metabolism & cause brain damage

  42. Phenylketonuria • Affected infant is normal at birth • Most common manifestation without treatment is developmental delay • MR develop gradually • Infant: severe vomiting, hypertonic, hyperactive DTRs, seizures; older: hyperactive with purposeless movements, rhythmic rocking & athetosis • unpleasant musty odor

  43. Neonatal Jaundice

  44. Breastfeeding jaundice: Onset at 3-4 DOL; 13% of breastfed infants Accentuated unconjugated hyperbilirubinemia Factors: decreased milk intake with dehydration; reduced caloric intake Duration is a few days Breast milk jaundice Onset after 7th DOL Increased B1 in 2% of breastfed term infants As high as 10-30 mg/dL during the 2nd-3rd week Factors: presence of glucuronidase in some breast milk Duration: 3 weeks to 3 months Jaundice related to breastfeeding

  45. To reduce incidence of breastfeeding jaundice: Frequent breastfeeding (>10/24 hrs) Rooming-in with night feeding Discouraging 5% dextrose or water supplementation Ongoing lactation support Breast milk jaundice: If breastfeeding is continued, bilirubin gradually decreases but may persist for 3-10 weeks at lower levels. If discontinued, serum bilirubin level falls rapidly. Phototherapy may be of benefit. Jaundice related to breastfeeding

  46. Small for Gestational Age • also known as intra-uterine growth retardation (IUGR) • BW is < 3rd percentile for calculated gestational age • growth of the fetus affected by fetal, uterine, placental and maternal factors • increased morbidity and mortality

  47. IUGR • Symmetric - earlier onset & associated with diseases that seriously affect fetal cell number like chromosomal, genetic, malformation, teratogenic, infectious, or severe maternal hypertensive etiologies • Asymmetric - late onset & associated with poor maternal nutrition or with late onset or exacerbation of maternal vascular disease

  48. Large for gestational age • maternal diabetes & obesity are predisposing factors • maternal hyperglycemia leads to fetal • hyperglycemia & hyperinsulinism • SSx: hypoglycemia, plethora • increased risk of: • respiratory distress syndrome • congenital cardiac defects • lumbosacral agenesis • hyperbilirubinemia

  49. Post-term infants • Born after 42 wks of gestation regardless of birth weight • Unknown cause • Their appearance & behavior suggest those of an infant 1-3 wks of age • Absence of lanugo & vernix caseosa, long nails, abundant scalp hair, desquamating skin & increased alertness • CS may be indicated for older primigravidas who go more than 2-4 wks beyond term

  50. Respiratory Distress Syndrome • due to deficiency or immaturity of surfactant • increased surface tension causes alveolar collapse & V/Q mismatch & hypoxia • seen in preterms – incidence is inversely proportional to gestational age (60-80% in <28 wks of gestation) • SSx: respiratory distress soon after birth • CXR: “ground-glass” pattern, air bronchograms • prevention: reach term, maternal steroids at least 48 hrs prior to delivery

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