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GENERAL PEDIATRICS LMCC Review

GENERAL PEDIATRICS LMCC Review. Presented by Marc E. Zucker MD, FRCPC Division of Pediatric Medicine CHEO March 22, 2010. Feeding & Growth. Breastfeeding. CPS recommends exclusive breastfeeding for babies up to 6 months (when possible) Breast milk has a caloric content of

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GENERAL PEDIATRICS LMCC Review

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  1. GENERAL PEDIATRICSLMCC Review Presented by Marc E. Zucker MD, FRCPC Division of Pediatric Medicine CHEO March 22, 2010

  2. Feeding & Growth

  3. Breastfeeding • CPS recommends exclusive breastfeeding for babies up to 6 months (when possible) • Breast milk has a caloric content of ~20 Kcal/oz (0.67 Kcal/ml) • Babies need 100-130 Kcal/Kg/day in 1st 3 months • Feeding/growth spurts occur at 8-12 days, 3-4 wks, 3 mo, variably after that

  4. Nutritionally, how does breast milk compare to cow’s milk? • Lower protein content - decreased solute load • Greater whey:casein (70/30 vs 18/82, formula 60/40) • CHO - both are lactose based (6.5% vs 4.5%) • Fat - 30-50% vs 3.5-4% • Vitamins - richer in A,C,E, lower in D & K • Minerals - lower Fe but better absorbed

  5. Breast Feeding Benefits for Baby • Immunological benefit • secretory IgA, lactoferrin, lysozyme as GI defence • Lower rate OM, LRTI, gastro, possibly UTIs, Hib • Less allergenic • Less constipating • Better jaw/mandible development • Attachment and ?Improved cognitive functioning

  6. Breast Feeding Benefits for Mother • Postpartum weight loss & uterine involution • Delayed return of fertility • Bonding • Pre-menopausal breast & ovarian Ca reduced • Economical benefit

  7. “Disadvantages” To Breast Feeding • Takes 3-7 days for milk supply to come in • risk of dehydration/ “breastfeeding jaundice” • Jaundice is more common • Breastmilk jaundice • “Mom/baby team” • ineffective latch/sore nipples/engorgement • Infections • thrush , mastitis/abscess • Reduced levels vitamin D & K

  8. Vitamin D Supplementation • Rickets is still a problem in Canada! • 400 IU per day • All Breastfed infants • Pregnant and nursing mothers in northern Canada • Formula Fed infants living in northern Canada • 800 IU per day - < 2 yrs breastfed babies with a risk factor • Home above 55 degree latitude, darker skin, sun avoidance • Community with high prevalence Vit D deficiency • Vitamin D is found in milk, margarine, salmon, tuna, liver, kidney & from the sun

  9. Contraindications to Breast Feeding • Maternal infections • HIV, AIDS, active TB, malaria, herpes on breast, hepatitis • Maternal sepsis • Psychotropic meds or others crossing • Chemo/radiation • Alcohol/drug abuse • Infant Galactosemia (lactose) • *May breastfeed even with VZV

  10. Cow’s Milk Formula • Always Fe fortified • Many choices! • Specialty formulas • soy, lactose free, increased calories • Protein hydrolysate formulas (eg.Alimentum, Nutramigen, Progestemil) • Amino-acid based formulas (Neocate)

  11. Introduction of Solids • cereals 4-6 months • vegetables • fruits • meats • cow’s milk should be postponed until at least 10-12 months of age (renal load) • 2% or 1% milk should be postponed until after second birthday (inadequate fat content) Rest gradually in this order

  12. Infant Growth: Rules of Thumb • Weight gain: • Regain birth weight by 10-14 days (max 10% loss) • Double birth weight by 5 months • Triple birth weight by 1 year • Quadruple birth weight by 2 years • Increase by 5 lbs/year for rest of childhood

  13. Growth - Height • Average length at birth 50 cm (20 inches) • Increases by 50% by 1 yr • Doubles by 4 yrs • Triples by 13 yrs • Ave growth 5-6 cm / yr (4 yrs-puberty)

  14. Growth- Body Mass Index (BMI) • BMI helps to quantify the weight to height relationship • BMI = weight(kg)/height (m)2 • BMI of 20-25 is acceptable • BMI > 30 indicates obesity • BMI < 18 suggest severe anorexia or Failure to thrive

  15. Growth- Head Circumference • 2 cm/month 1-3 months • 1cm/month 3-6 months • 0.5cm/month 6-12 months • Most of growth is in first yr! • 12 cm in first yr, 2 cm in 2nd yr, 6-8 cm rest of life

  16. Growth Monitoring • Routinely recommended • Height, weight, head circumference • Plot on appropriate chart considering ethnicity, genetic syndromes (eg. Tri 21, Turner’s), and prematurity • Prematurity, correct hc (18 mo), wt (24 mo), ht (40 mo) • Only way to detect FTT • Also detects chronic illness, feeding difficulties

  17. What is Failure to Thrive? • US National Center for Health Statistics defines FTT for children < 2 yrs of age as: • Weight <3rd-5th centile for age on more than one occasion • Weight <80% of ideal body weight for age • Weight crosses 2 major centile curves downwards on a standardized growth curve • Exceptions: genetic/familial short stature, constitutional growth delay, SGA infants & preterm infants

  18. Caloric needs • 0-10 kg: 100 kcal/kg/day • 10-20 kg: 1000 + 50 kcal/kg/day • >20 kg: 1500 + 20 kcal/kg/day

  19. FTT- Infant Growth • Caveats to normal growth velocity: • >50% of babies shift their growth parameters upwards between birth and 3 months • Nearly 30% of well babies shift their parameters downwards between 3 and 18 months • Exclusively breastfed babies plot higher for wt at 0-6 months and lower at 6-12 months5

  20. Growth Velocity • Average age to “settle” on a growth curve is 13 months6 • Downward shift seen with constitutional growth delay • downward shift between 6 & 24 months • may have decreased weight for height • re-establish normal growth velocities by 3 yrs *Genetically Programmed curve is established by 18-24 months

  21. FTT- Assessment • Grading of malnutrition:

  22. FTT- Assessment • “Organic” vs. “non-organic” • Historical way of viewing FTT • Refers to presence/absence of diagnosis of major disease process or organ dysfunction • “Non-organic” accounts for >80% • Now felt to be more of a continuum • Multifactorial process

  23. FTT- Assessment • Under-nutrition results from: 1) Decreased caloric intake 2) Inadequate caloric absorption 3) Increased caloric losses 4) Increased caloric requirements

  24. FTT- Differential Diagnosis • Decreased caloric intake: • Inadvertent (decreased breast milk, improper formula preparation) • Neglect or abuse • Behavioural (ex. Food refusal) • Pain (GERD, injury to mouth or esophagus) • Fatigue /anorexia (anemia, cardiac dz, resp dz, RTA) • Impaired swallowing (neurologic dz) • Craniofacial abnormalities (cleft lip/palate, choanal atresia) • Toxin (lead)

  25. FTT- Differential Diagnosis • Inadequate Caloric Absorption & Increased Caloric Losses • GI • Pancreatic insufficiency (CF) • Liver disease (biliary atresia, chronic cholestasis) • Generalized malabsorption (CF, Celiac, short gut) • Diarrheal state (infectious, post-infectious) • Persistent vomiting (pyloric stenosis, GERD) • Inflammatory disorders (IBD) • Allergic gastroenteropathy • Protein-losing enteropathy

  26. FTT- Differential Diagnosis • Increased Caloric Losses cont’d • Renal • Protein loss • Carbohydrate loss • Inability to use nutrients • Diabetes Mellitus • Metabolic dz

  27. FTT- Investigations • Careful and complete history taking and physical examination are ESSENTIAL • Unless an illness other than primary under-nutrition is suspected on Hx or P/E the yield of lab investigations is almost nil! • Lab testing helps with diagnosis in 1.4%

  28. FTT- Investigations • Non-specific “screening” • CBCD, ESR, lytes, BUN, Cr, venous gas • Urine R&M, C&S • Markers of nutritional status • Total protein, albumin, glu, Ca, PO4, Iron studies • Zinc, vitamin levels • Dependent on specific aspects of Hx & P/E • Liver function tests • Thyroid studies • Stool OB, reducing substances, culture, O&P, trypsin • Sweat test, immunoglobulins & celiac screen, viral serology (incl HIV), TB testing, immune w/up, metabolic w/up, CXR, ECG, milk scan

  29. FTT- Management • Admit if : • Suspect enviro. deprivation/neglect/abuse • Suspect chronic dz which needs stabilizing • Severe under-nutrition (consider if moderate) • ie. <60% of median weight for age • Failed out-patient management • With hospitalization: • greater likelihood of catch-up growth • no change in developmental outcomes

  30. FTT- Management • Inter-disciplinary approach!! • Treat any underlying illness and provide nutritional support: • Increase caloric intake • 1.5-2 X RDA • (120 kcal/kg/day x ideal wt)/current wt • Estimate 150-200 kcal/kg/day

  31. FTT- Management • Mild under-nutrition • Ensure frequent feedings (q 3 hrs) • Increase formula concentration (eg. 24 kcal/oz) • Add calorie-rich foods to diet (butter, PB, oils) • Provide dietary counseling • Prescribe multivitamin with zinc and iron • Follow-up frequently (?public health nurse) • Expect catch-up growth at 2-3x regular rate in first month

  32. FTT- Management • Moderate under-nutrition • Determine caloric intake • Consider whether investigations are necessary • Increase caloric intake (150-200 kcal/kg/day) • Ensure adequate protein (3-4 g/kg/day) • Consider meal supplements (eg. Pediasure) • Add Multivitamin • Consider therapeutic doses of iron • Monitor weight gain

  33. FTT- Management • Severe under-nutrition • Admit • Initiate re-feeding slowly • Consider using elemental formula • Consider diluting formula • May need ng continuous feeds or tpn • Follow fluid and lytes status closely

  34. FTT- Long-term implications • Persistent growth deficits • Cognitive impairment • Behaviour problems

  35. IMMUNIZATIONS

  36. Age 2 mos 4 mos 6 mos 12 mos 18 mos 4-6 year q10 years Vaccine DaPTP-HIB, Prevnar, Menj DaPTP-HIB, Prevnar,Menj DaPTP-HIB, Prevnar,Menj MMR, Varicella, Prevnar DaPTP-HIB, MMR DaPTP dTaP/dT Immunization Schedule(Recommended by the Canadian Immunization Guide)

  37. Contraindications to Vaccines • Strict - anaphylaxic or anaphylactic shock - encephalopathy • Precautions - febrile reaction > 40.5 - shock collapse or hypotonia - hyporesponsive collapse - seizures

  38. Contraindications to vaccines • Anaphylaxis to eggs: • Influenza and yellow fever • Severe immune deficiency: • All live vaccines (MMR, VZV, OPV, BCG, Yellow fever, Oral cholera, Oral typhoid) • Pregnancy: • MMR and Varicella • Anaphylaxis to neomycin: • MMR and IPV

  39. Immunization Reactions • DaPTP/Hib • reactions occur within 72 hrs • MMR • reactions occur 5-12 days

  40. Age 1-6 years 0 mos:DPTP-Hib, MMR,HepB, P,V,MC 2 mos: Pentacel,MMR,HepB, Prevnar 4 mos: DPTP 12 mos:DPTP 4-6 yrs: DPTP 14-16 yrs: dTaP > 7 Years Old 0 mos: TdaP,Polio, MMR,V,Menj,HepB 2 mos: TdaP, Polio, HepB,MMR, V 6-12 mos: TdaP+Polio,HepB TdaP (no polio) q10 yrs thereafter Delayed Immunization

  41. Other Immunizations • Hepatitis A & B • Influenza • HPV • Rotavirus

  42. INFECTIOUS DISEASE

  43. Fever • Temp > 38.3 Celsius rectal • Occult bacteremia: most in 3-24 mos • 3-5% febrile are bacteremic • most common org. is Strep. Pneumo ** • 0-1 mos: FSWU • 1-3 mos: • toxic = FSWU • non-toxic and low risk (WBC 5-15, bands <5%, urine neg, well-looking, reliable family): investigate and follow

  44. Otitis Media • Incidence: • 15% to 20% • Peak: • 6 to 36 months • 4 to 6 years • decreases > 6 years old • Etiology: S. pneumoniae, M. catarrhalis, non-type H. Flu, GAS & viral

  45. Otitis Media • Risk Factors • mid-face hypoplasia (Down Syndrome) • daycare attendance • Inuit/Aboriginal • low SES • 2nd hand smoke

  46. Otitis Media • Treatment: • 1st line: Amoxil • 2nd line: High dose Amoxil, Clavulin, Macrolides, Cephalosporin • T-Tubes if recurrent or persistent effusion • Complications: • hearing loss • chronic effusion • mastoiditis • meningitis

  47. Sinusitis • Mainly ethmoid sinus • Predisposed by viral URTI, allergy, asthma, periodontal disease • Same bugs as OM +/- anaerobes • Presents with fever, purulent nasal discharge (> 10 days), periorbital tenderness, halitosis • Treat with same Abx as OM, may need longer course (3 weeks)

  48. Meningitis • Newborn period (LEG) • Listeria • E. Coli • Group B strep • 2 months - 12 years (SHIN) • Strep pneumonia, N. meningitides • Less common Hib with immunization

  49. Meningitis • in abnormal hosts or anatomic defects: • increased Pseudomonas, Staph, Salmonella, Serratia • Complications • SIADH • seizures • subdural effusions • transient joint effusions (Ag-Ab reaction) • hearing loss

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