MEDLEY OF UPDATES

1. MEDLEY OF UPDATES PAEDIATRIC SOCIETY Dr Sridevi Arikala

2. Updates • ALTE- Acute Life threatening Event • SIDS- Sudden infant death syndrome. • ADHD- Attention deficit hyperative disorder • Autism • Cows milk allergy.

3. Acute Life Threatening Event An episode in an infant that is frightening to the observor • Apnoea 20 seconds or longer • Colour change – cyanosis or pallor • Marked change in muscle tone • Choking or gagging Diagnosis based on symptomatology rather than pathophysiology

4. Differential diagnosis Central Obstructive • Seizure • Breath holding spell • Metabolic • Cardiovascular • Infection • Drugs • GE reflux • Acute abdomen • LRTI • Foreign body • NAI

5. Paediatrics in Review June 2012 • 50% - Cause not known • GE reflux ; Seizure and LRTI- 50% Recently recognised risk factors • Post conceptional age of < 48 weeks in preterm babies • Post natal age of < 1 month • First 2 hours after birth-Most cases are obstructed airway; frequent checks by health personnel.

6. Investigations- Dutch Pediatric Association. • CBC • C-reactive protein • Blood glucose • Arterial blood gas • Urine analysis • ECG • RSV/Bordetella

7. What this update adds • EEG Diffiult to obtain in emergency setting Sensitivity of EEG 15 % in diagnosis( Bonkowsky et al-2008) Patients with epilepsy will return with a second episode EEG reserved for children with recurrent ALTE

8. What this update adds • CT scan reserved for children with suspected child abuse. • Multiple history taking from caregivers to note discrepancies. • Fundus exmination and Skeletal surveys to follow. • Serum Metabolic Studies – Organic acidemias ; Urea cycle disorders ; fatty acid oxidation defects and mitochondrial disorders cause 2-5% of ALTE • Serum electrolytes – Na;K; Ca; Mg; Ammomia; lactate pyruvate

9. What this update adds • Urine toxicology- Usually cold and cough mixtures. • Gastroesophageal reflux-Ph probe testing showing reflux should coincide with respiratory symptoms Reserved for infants with frequent GE reflux ; ALTE preceded by feeding; milk found in mouth and nose • Hospital admission –Recommend 24 hours of observation . • Resources for infant basic life support Courses.

10. Update on SIDS Paediatrics in Review June 2012 American academy of Paediatrics SIDS Task force recommendations.

11. Definition Of SIDS • Sudden unexplained death before 1 year of age. • Previously healthy infant. • Cause of death unexplained despite case investigation. complete autopsy. death scene investigation. review of clinical history.

12. Risk reduction factors for SIDS • Back to sleep for every sleep. • Use a firm sleep surface. • Keep soft objects and bedding out of the crib. • Avoid tobacco smoke. • Room sharing without bedsharing. • Pacifier at nap time and bed time. • Avoid overheating. • Do not use cardiorespiratory monitors as strategy to reduce risk of SIDS.

13. What this update adds • Reduction in SIDS cases. • Rise in cases of ASSB- Accidental suffocation and strangulation in bed.

14. What this update adds. Bed sharing particularly dangerous • Infant < 2-3 months of age • One or both parents are smokers. • Infant is placed on sofa; arm chairs or waterbeds. • Multiple bed sharers. • Person bed sharing has consumed alcohol; medications or illicit drugs.

15. What this update adds. • Breast feeding- protective effect on SIDS. Decreased infectious diseases. Breast fed infants more easily aroused than formula fed infants. • Pacifier- protective effect on SIDS However to be introduced 2 to 4 weeks of age.

16. What this update adds • Room ventilation and fans- Currently no recommendation for or against fan use as SIDS risk reduction strategy. • Swaddling- No recommendation for or against swaddling as risk reduction strategy. Swaddle should not be tight so as to effect respiration or exacerbate hip dysplasia. Not loose as to create head covering; suffocation or strangulation.

17. ADHD and Autism Update

18. Diagnostic and statistical manual of mental disorders.

19. Attention deficit Hyperactive disorder • Update based only on Diagnostic Criteria. • Previously Diagnostic and Statistical Manual of mental disorders IV was used. • DSM-5 published in May 2013 • Diagnosis still based on Inattention- 6/9 criteria and/or 6/9 of hyperactive/impulsivity criteria

20. What this Update adds DSM IV DSM V • Grouped under Disruptive behavioural disorder • Diagnostic criteria predominantly for children Easily distracted- extraneous objects Forgetful of dialy activities- Running errands Child runs about • Grouped under Neurodevelopmental disorder • Illustrated examples of behavior for adults/children Adults- Unrelated thoughts Forgetful of daily activities- Paying bills/keeping appointment Adult- Feeling restless

21. DSM IV DSM V • 6/9 of inattentive and or 6/9 of hyperactive/impulsive criteria • Symptoms should have been present before 7 years • Symptoms should cause significant impairment in social; academic or occupational functioning. • Over 17 years 5 criteria are sufficient • Symptoms should have been present before 12 years. • Symptmoms should intefere with or reduce quality of life in social academic or occupational functioning.

22. DSM IV DSM V • Exclusion criteria for ADHD Pervasive devt disorder Schizophrenia Other psychotic disorder • Subtype Classification Combined Type. Predominantly inattentive Predominantly hyperactive • Severity • Exclusion criteria for ADHD Schizophrenia Other psychotic disorder • Subtype Classification Combined presentation Predominantly inattentive hyperactive presentation • Mild ; moderate; severe

23. Update on Autism. DSM-IV DSM-V Pervasive developmental disorders • Autism • Aspergers syndrome • PPD-NOS • Retts syndrome • Childhood disintegrative disorder Autism Spectrum disorder Autism Aspergers syndrome PPD-NOS Childhood disintegrative disorder

24. Shift from categorical to Dimensional • Categorical subtypes- clinical diagnosis not reliable. • Few differences between high functioning Autism and Asperger’s • One spectrum of autistic disorders defined purely by behaviours

25. 3 key domains become 2 DSM IV DSM V • 3 criteria • Social impairment and communication • Restricted and repititive behaviour

26. Rationale for dyad • Multiple criteria assess same symptom • Deficits in communication and social behaviors are inseparable. • Delays in language are not unique nor universal in ASD .

27. Social Impairment and Communication • Deficits in social-emotional reciprocity • Deficits in nonverbal communicative behaviors • Deficits in developing and maintaining relationships, appropriate to developmental level. All three need to be present- increase specificity.

28. Restricted/Repetitive behaviour • Stereotyped or repetitive speech • Excessive adherence to routines • Highly restricted, fixated interests • Hyper-or hypo-reactivity to sensory input Two RRB instead of one- improves specificity.

29. ASD –DSM5 Specifiers and Modifiers • With the new criteria, if the child meets for ASD he / she will receive a diagnosis with the etiology as a specifier –ASD with Rett Syndrome –ASD with Fragile X • OR with a modifier indicating another important factor –ASD with tonic-clonic seizures –ASD with intellectual disabilities

30. Levels of severity DSM V • Level One - Requiring support. • Level Two- Requires substantial support • Level Three- Requires very substantial support.

31. Cows milk Allergy – ESPGHAN guidelines 2012 Immediate Reaction Late Reactions • Dermatological: Angio-oedema, urticaria, pruritis, erythema. • Respiratory: Rhinitis, chronic cough/ wheeze (unrelated to infection), acute laryngoedema. • Systemic: Anaphylaxis. • Gastrointestinal: Quick onset vomiting and diarrhea (within 2 hours) • Dermatological: Atopic eczema. • Gastrointestinal: Reflux, diarrhoea constipation, blood in stools (colitis) iron deficiency anaemia growth faltering

32. Investigations for CMPA Skin tests and positive IgE • Indicate sensitisation and may not mean allergy. • Quantification of these tests useful in prognosis • Negative in gastrointestinal reactions. Elimination diet and Oral challenge- Gold standard for diagnosis

33. Breast Fed Infants • Continue breast feeding • Elimination of CMP from mother’s diet • No improvement- Diagnosis unlikely • Improvement- Oral challenge and if symptoms recur elimination diet for the mother weaning onto EHF

34. Formula fed infants- Elimination diet • Extensively hydrolysed formula First choice for most infants.. • Aminoacid formula If EHF does not work. Costly. • Soy based formula > 6 months. Taste better. Less costly. Risk of micronutreint deficiency

35. Formula fed infants- Severe reactions • Skin prick test positive or IgE positive oral challenge not required. • CMP protein free diet for one year. • Reevalaution done after 1 year under controlled circumstances

36. Neither clear nor severe Reactions • Oral challenge for 2 weeks. • If positive; elimination diet for 6 mon. • Skin test negative or low titres of IgE antibody reevalation after 6 months and can be done at home. • Prognosis 50% tolerance by 1 year 75% tolerance by 3 years 90% tolerance by 6 years.