Addendum: Pediatrics Review

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 plates • 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.