Principles of Pediatrics by Adeleke

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 Principles of Pediatrics by Adeleke

TABLE OF CONTENT

1. History Taking In Pediatrics ---------------------------------------------------------1-4

2. Pediatric Anthropometry ------------------------------------------------------------5-8
3. Intravenous Fluids In Pediatrics ----------------------------------------------------9-11
4. Fluid And Electrolyte Management -----------------------------------------------12-18
5. Neonatal Jaundice --------------------------------------------------------------------19-26
6. Perinatal Asphyxia --------------------------------------------------------------------27-33
7. Neonatal Tetanus ---------------------------------------------------------------------34-39
8. Low Birth Weight ---------------------------------------------------------------------40-45
9. Respiratory Disorders In The Newborn ------------------------------------------46-50
10. Seizure Disorders ----------------------------------------------------------------------51-57
11. Cerebral Palsy --------------------------------------------------------------------------58-61
12. Febrile Seizures ------------------------------------------------------------------------62-64
13. Congenital Heart Diseases -----------------------------------------------------------65-72
14. Heart Failure In Children -------------------------------------------------------------73-76
15. Infective Endocarditis -----------------------------------------------------------------77-79
16. Pneumonia ------------------------------------------------------------------------------80-85
17. Tuberculosis ----------------------------------------------------------------------------86-94
18. Acute Laryngotracheobronchitis (Croup) ---------------------------------------95-98
19. Diarrheal Disease ---------------------------------------------------------------------99-105
20. Protein Energy Malnutrition -------------------------------------------------------106-113
21. Acute Glomerulonephritis ----------------------------------------------------------114-116
22. Acute Kidney Injury -------------------------------------------------------------------117-121
23. Nephrotic Syndrome -----------------------------------------------------------------122-126
24. Sickle Cell Disease --------------------------------------------------------------------127-132

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 Principles of Pediatrics by Adeleke

25. Burkitt Lymphoma -------------------------------------------------------------------133-137

26. Malaria ----------------------------------------------------------------------------------138-145
27. Embryonal Tumors ------------------------------------------------------------------146-151
28. Osteomyelitis -------------------------------------------------------------------------152-155
29. Measles (Rubeola)-------------------------------------------------------------------156-159
30. Vaccines And Immunization-------------------------------------------------------160-162
31. Guide On History Of Common Presenting Complaints --------------------163-165
32. Instrumentation In Pediatrics -----------------------------------------------------164-174
INDEX------------------------------------------------------------------------------------175-178

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 Principles of Pediatrics by Adeleke

- A term baby doubles its BW around 4-5 mo and triples it around 12 months
- Daily weight gain is 20-30 g in the first 3-4 mo, and 15-20 g for the rest of 1st yr
- Measuring device: Bassinet weighing scale (at <2 yr) or Stadiometer (at ≥2 yr)

 Formulas for Estimating Child’s Weight from Age

Age Formula N
1 - 90 days (n - 10) x 30 + birth weight n - age in days
4 - 12 mo n + 9/2 n - age in months
1 - 6 yr 2n + 8 n - age in years
7-12 yr 7n - 5/2 n - age in years

Bassinet Weighing Scale Adopted from Google Stadiometer

 Length/Height
- Length is measured in children < 2 yr using the Infantometer
- An assistant helps to maintain the child in supine position on the measuring board
while measurement is being taken
- Height is measured in children > 2 yr, who are able to stand upright without support,
using the Stadiometer
- Worthy of note is that length is about 1-2cm greater than height, as joint spaces are
reduced by gravity while standing
- Normal length at birth: 50 ± 5 cm. It increases by ~25 cm in the first yr
- By age 4-5 yr, an average child would have double the birth length

 Rate of increase in length in infancy

Age 1 - 3 mo 4 - 6 mo 7 - 9 mo 10 - 12 mo
Rate 3.5 cm/mo 2.0 cm/mo 1.5 cm/mo 1.3 cm/mo

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 Principles of Pediatrics by Adeleke

 Causes: diarrhea, vomiting, nasogastric suction, fever, burns, radiant warmer,

phototherapy, sweat, tachypnea, tracheostomy, polyuria, surgical drain, third
spacing etc.

 Fluid Replacement Therapy

- Fluid replacement therapy comprise the following:
• Deficit therapy
• Maintenance therapy
• Replacement of ongoing loss

 Deficit Therapy
 Mild dehydration (about 50ml/kg of body fluid or 3-5% BW has been lost)
- 50ml/kg of Oral Rehydration Solution (ORS) is administered over 4hrs (i.e. 500ml for
a 10 kg child)
- Child is then reassessed; fluid can be repeated if dehydration persists

 Moderate dehydration (about 75ml/kg of body fluid or 6-10% BW has been lost)
- 75ml/kg of ORS is administered over 4hrs (i.e. 750ml for a 10 kg child)
- Child is then reassessed; fluid can be repeated if dehydration persists

 Severe dehydration (about 100ml/kg of body fluid or > 10% BW has been lost)
- 20 ml/kg of isotonic solution (NS or RL) is infused intravenously over 20 min (this
fluid is subtracted from the total deficit)
- Child is then reassessed; infusion can be repeated if dehydration persists

 Maintenance Therapy
- This replaces fluid loss via the skin, lungs and urine so as to prevent relapse of
dehydration
- It is estimated from patient weight as follows:
. 100ml/kg for the first 10kg
. 50ml/kg for the next 10kg
. 20ml/kg for each kg above 20kg
 Thus, maintenance fluid for a child weighing 24kg will be 1580 ml
- If child can drink: maintenance is given orally as ORS (preferred) but
 Pharmacotherapy

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 Principles of Pediatrics by Adeleke

• Phenobarbital: augments hepatic uptake of bilirubin and increases the activity of

glucuronosyltransferase; thus, enhances bilirubin conjugation and eventual
excretion from the body
• Tin-mesoporphyrin: inhibits the production of heme oxygenase (inhibiting
conversion of heme to biliverdin)
• Intravenous immune globulin (IVIG): in immunologically mediated conditions such
as Rhesus, ABO, and other blood group incompatibilities.
- It significantly reduces need for EBT

 Phototherapy
- An inexpensive and non-invasive method first described by Cremer et al in 1958
- Light energy photo-isomerizes bilirubin into photo-bilirubin or lumirubin (a more
polar, less lipophilic, more acidic, and easily excretable form)

 Indications
- Prophylaxis in preterm LBW infants
- Moderate hyperbilirubinemia
- To accelerate excretion, and prevent rebound hyperbilirubinemia post-EBT

 Contraindication: Personal or family history of Porphyria

 Phototherapy lights: broad-spectrum white light , broad-spectrum blue light,

narrow-spectrum blue light, fiber optic light and light emitting diode (LED)

Jaundiced baby receiving phototherapy Adopted from Google

- 8hrs of life; before which it is representative of maternal values)

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 Principles of Pediatrics by Adeleke

 Principles of Care of LBW Baby

- Following stabilization in the delivery room, the following are done on admission in
the Special Care Baby Unit (SCBU):

 Thermal control
- Incubator or radiant warmer: should be used to maintain the infant’s core
temperature at 36.5-37.0oC (to minimize heat loss and oxygen consumption)
- Kangaroo mother care: direct mother and baby skin-to-skin contact and a hat and
blanket covering the infant is a safe alternative

 Intravenous fluid
- 70-80 ml/kg/day (60 ml/kg/day if asphyxiated) of 10% dextrose in water on day 1,
then increase by 10ml/kg on subsequent days to a maximum of 150ml/kg/day
- Electrolyte containing fluids (usually 4.3% D/S) are used after 48 hr of life

 Feeding (Expressed breast milk (EBM))

- Late preterms (≥ 34 weeks): are fed by bottle or directly at the breast
- Early preterms (< 34 weeks): are fed by bottle or gavage feeding
- For VLBW babies, feeding may be initiated with buccal colostrum, then to trophic
feeding (e.g. 1ml of EBM 2-4hrly) to graded enteral feeding (e.g. 2ml of EBM 2hrly
which is increased by 1ml 8hrly or 12hrly, as tolerated)
- Parenteral nutrition is an alternative where complete enteral feeding has not been
established or when enteral feeding is impossible for prolonged periods

 Respiratory Support
- Oxygen should be administered via a head hood, nasal cannula, continuous positive
airway pressure (CPAP) apparatus, or endotracheal tube to maintain stable and safe
inspired oxygen concentrations

 Prevent or Treat the Following:

- Hemorrhagic disease of newborn: IM Vitamin K, 0.5mg stat. (1mg in terms)
- Apnea of prematurity: IV aminophylline 6 mg/kg stat. then 1 mg/kg 12 hrly
- Neonatal jaundice: phototherapy and/or exchange blood transfusion
- Anemia and Nutrient deficiencies: supplements (folic acid, iron, calcium,
phosphorus, amino acids, vitamin A, B, C, D)

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 Principles of Pediatrics by Adeleke

- However, not all myoclonus is epileptic in nature; for example, the myoclonic jerks
during phase 1 of sleep are normal release phenomenon

 Treatment: Na valproate, lamotrigine, topiramate

Child having a GTCS Adopted from Google

 Atonic Seizure (Drop Attacks)

- Atonic seizure is characterized by sudden, brief (1-2 sec) loss of postural muscle
tone, causing the child to fall to the ground, and possibly sustain injuries
 Treatment: Na valproate, personal protective equipments (helmet, face guard)

 Absence Seizure (Petit Mal Seizure)

- Absence seizure is characterized by short (<20 sec) loss of consciousness during
which:
• Patient neither change posture nor drop objects being held (typical AS) or
• Patient makes minor movements such as blinking, lip smacking, tagging on the
clothes etc. (atypical AS)
- Patient regains consciousness to continue previous action
- It typically begin in childhood (5-8 yrs) and may persist into adulthood
- Patient have several episodes per day without aura or post-ictal symptoms
- Hyperventilation and photic stimulation frequently precipitate these seizures
- Neurologic examination and neuroimaging are usually normal

Treatment: ethosuximide, Na valproate

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 Principles of Pediatrics by Adeleke

 CYANOTIC CONGENITAL HEART DISEASES

 Tetralogy of Fallot (ToF)
- ToF is the most common cyanotic CHD, and represents about 10% of all CHDs
- It occurs due to abnormal septation of the truncus arteriosus into the aorta and
pulmonary artery early in gestation (3-4 wk)

 Component
• VSD: usually large; shunting oxygenated blood from left to right ventricle
• Pulmonary Stenosis: obstructing outflow of blood from the right ventricle to the
lungs (the degree of PS is the key determinant of severity in ToF)
• Dextropositioned Aorta: so that it overrides (i.e. lies directly above) the VSD
• Right Ventricular Hypertrophy: a consequence of right ventricular overload

 Clinical features
- Babies usually remain acyanosed until later in infancy
- Exertional dyspnea, feeding difficulties, failure to thrive, squatting, cyanosis,
polycythemia, digital clubbing, stroke, cerebral abscess etc.
• CVS findings: pansystolic murmur at LLSB or ejection systolic murmur at LUSB, a
single S2, and left parasternal heave with or without systolic thrill
• CXR: shows boot-shaped heart (Coeur en sabot) seen as uplifted cardiac apex, and
diminished prominence of the pulmonary arteries
• ECG: RVH, right bundle branch block

Normal Chest Radiograph Adopted from Google Tetralogy of Fallot

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 Principles of Pediatrics by Adeleke

 Gomez classification
- It classifies PEM based on the deficit in weight for age

Weight for Age Nutritional Status

(%)
>90 Normal
76-90 First degree malnutrition
60-75 Second degree malnutrition
<60 Third degree malnutrition

 Modified Welcome classification

- This classifies children based on the deficit in their weight for age and the presence
or absence (+/-) of edema

Weight for Age (%) Edema Nutritional Status

80-120 - Normal
80-120 + Kwashiorkor
60-80 - Underweight
60-80 + Underweight kwashiorkor
< 60 - Marasmus
< 60 + Marasmic kwashiorkor

• % weight deficit = Observed weight x 100

Expected weight

 Kwashiorkor (Ghana’s Ga language: Sickness of weaning)

- It results from inadequate protein intake with fair or good caloric intake
- Characteristically affects children who are being weaned (age 1-3 yr)

 Clinical features
Constant Common Occasional
Growth failure Moon face Flaky paint dermatoses
Muscle wasting Skin dyspigmentation/desquamation Skin ulceration/fissuring
Edema Brown, sparse, easily plucked hair Enlarged fatty liver
Mental Changes Pallor Micronutrient deficiency
(apathy, irritability) Hypothermia (stomatitis, cheilosis,
Diarrhea glossitis)

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 Principles of Pediatrics by Adeleke

 Indications for renal biopsy in NS

- Steroid resistant nephrotic syndrome
- Age <1 yr or >8 yr
- Recurrent gross hematuria
- Associated renal insufficiency
- Hypocomplimentemia (low C3/C4), positive ANA or dsDNA
- Relevant family history of kidney disease or symptoms of systemic disease

 Treatment
 Supportive Care
- Daily weighing, daily urinalysis, blood pressure monitoring, Na restriction, fluid
monitoring, moderate exercise to prevent thromboembolic event etc

 Corticosteroid therapy
- > 95% of minimal change NS respond to corticosteroid therapy
• Prednisone or prednisolone should be administered as follows:
- 60 mg/m2/day or 2 mg/kg/day (maximum, 60 mg/day) for 4-6 wk. Then,
- 40 mg/m2 or 1.5 mg/kg (maximum, 40mg) on alternate-day for a period ranging from
8 wk to 5 mo, with tapering of the dose

• Complications of Long-term Steroid: cushingoid appearance, cataract, infection,

hypertension, growth delay, osteopenia, hyperglycemia, avascular necrosis etc.

 Possible Outcomes of Corticosteroid Therapy

• Response: is attainment of remission within first 4 wk of corticosteroid therapy
• Remission: presence of <1+ protein on urine dipstick (or urine protein:creatinine
ratio of <0.2) for 3 consecutive days
• Relapse: is presence of ≥3+ protein on urine dipstick (or urine protein:creatinine of
>2) for 3 consecutive days
• Steroid Resistance: is failure to achieve remission after 8 wk of corticosteroids

 Steroid resistant NS is caused by FSGS in about 80% of cases

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 Principles of Pediatrics by Adeleke

Bantu/Central African Republic most severe, produces the least HbF

Benin moderate clinical severity and HbF production
Cameroon moderate clinical severity and HbF production
Saudi Arabia/India less severe, produces high level of HbF
Senegal less severe, produces high level of HbF

 CLINICAL MANIFESTATIONS OF SCA

 Acute Presentations (Crises)
 Vaso-occlusive Crisis (VOC)
- VOC is the most common clinical manifestation of SCA, and dactylitis (hand-foot
syndrome) which is the first presentation of the disease (at 6-24 mo) is a VOC
- Pathophysiology: See above (Vascular Occlusion)
- Forms of VOC: bone pain crisis, abdominal pain crisis, acute chest syndrome renal
papillary necrosis, stroke/TIA, avascular necrosis, priampism etc.
- Triggers: stress, infection, dehydration, hypoxia, acidosis, temperature extremes

 Bone Pain Crisis (BPC)

- BPC is the clinical hallmark of SCA, and the reason behind most hospital visits
- It results from nociceptive fibers stimulation following bone marrow infarction
- 6-24 mo: infarction occurs in small bones of hands and feet (dactylitis)
- Older children: infarction occurs in long bones, vertebrae, pelvis, ribs etc.
- Treatment: adequate analgesia (acetaminophen, NSAIDs, DF118, morphine),
hydration, temperature control, antibiotics, and oxygen (if hypoxic)

 Acute Chest Syndrome (ACS)

- ACS is characterized by chest pain, cough, dyspnea, tachypnea and evidence of new
infiltrate on chest radiograph
- It results from lung infection, and infarction following pulmonary vasoocclusion
- Common organisms: S. pneumoniae, Mycoplasma pneumoniae, Chlamydia sp.
- Examination: dull percussion note and reduced breath sound
- Treatment: oxygen, IV fluids, judicious analgesia, antibiotics, incentive spirometry,
bronchodilators, red cell transfusion, and rarely, EBT

 Priampism (low-flow type is seen in SCA)

- Defined as persistent, purposeless, painful penile erection

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 Principles of Pediatrics by Adeleke

CHAPTER 27: EMBRYONAL TUMORS

 NEUROBLASTOMA
- This is an embryonal malignancy of the peripheral sympathetic nervous system
arising from neural crest cells (neuroblasts)
- About half of cases arise in the adrenal glands, and others in the paraspinal ganglia,
neck, thorax and pelvis

 Epidemiology
- It is the most common extracranial solid tumor of infancy
- Median age at diagnosis is 2 yr; about 90% are diagnosed before 5 yr
- It is slightly more common in boys

 Etiology: mostly unknown

 Genetics: most cases are sporadic, only about 1-2% are familial
- Familial cases occur at a younger age, and are associated with mutations in PHOX2B
and ALK genes
- ~25% of sporadic cases are associated with amplification of MYCN proto-oncogene;
which is associated with rapid tumor progression and poor outcomes

 Associated anomalies: Hirschsprung disease, central hypoventilation syndrome, and

neurofibromatosis type I

 Clinical Presentation: depends on tumor site and extent of the disease

 Tumor site
- Neck: Horner syndrome (unilateral ptosis, myosis, and anhidrosis)
- Paraspinal: Spinal cord and nerve root compression

 Extent of the disease

- Localized tumor: may be asymptomatic or produce mass effect such as spinal cord
compression, bowel obstruction etc
- Metastatic tumor: fever, irritability, failure to thrive, bone pain, cytopenias, bluish
subcutaneous nodules, orbital proptosis, and periorbital ecchymoses

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 Principles of Pediatrics by Adeleke

CHAPTER 30: VACCINES AND IMMUNIZATION

- Immunization is one of the most beneficial and cost-effective disease prevention

measures available
 Immunization: is the process of inducing immunity against a specific disease
 Vaccination: is the introduction of vaccine into the body for the purpose of inducing
immunity
 Passive immunity: is achieved by administration of preformed antibodies to induce
transient protection against an infectious agent
 Active immunity: achieved by administering a vaccine or toxoid to stimulate the
immune system to produce a prolonged humoral and/or cellular immune response

 Immunizing Agents
 Vaccines: are whole or parts of microorganisms administered to prevent an
infectious disease. There are two types:
• Live attenuated vaccines: these are derived from disease-causing viruses or bacteria
that have been weakened under laboratory condition; thus,
- They cannot cause full blown disease but still has the ability to induce immunity
• Inactivated vaccines: here, the organisms are killed by heat or chemical, but still
retain their ability to induce immunity
 Toxoid: is a modified bacterial toxin that is made nontoxic but is still able to induce
an active immune response against the toxin

Live attenuated Inactivated Toxoid Recombinant Polysaccharides

Bacterial Bacterial Bacterial Viral Bacterial
BCG Typhoid Diphtheria Hepatitis B N. meningitides
Typhoid Cholera Tetanus HPV (Human S. pneumoniae
Pertussis Papillomavirus) H. influenza type b
Viral
MMR Viral
Oral polio (Sabin) IPV (Salk)
Rotavirus Hepatitis A
Yellow fever Rabies
Influenza Influenza
Varicella
MMR - Measles, Mumps, Rubella BCG - Bacille Calmette-Guerin IPV - Inactivated Polio Vaccine

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 Indication: small children and patient
who cannot comply with respiratory
maneuvers of MDI
 Advantages of MDI with spacer over
MDI alone
- Eliminates need for correct actuation
and inhalation coordination when
using MDI alone
- Gives better drug delivery to the
airways, thus more cost effective
- Eliminates Cold Freon effect (sudden
cessation of inspiration when the
cold aerosol hits the oropharynx)
- Reduces local side effect of steroid
- Almost as effective as nebulizer in
managing asthma attacks
ENDOTRACHEAL TUBE
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Principles of Pediatrics by Adeleke
 Indication
- Inability to maintain airway patency
e.g. croup
- Inability to protect the airway against
aspiration e.g. unconscious patient
- Failure to ventilate e.g. Apnea
- Failure to oxygenate e.g. RDS, severe
pneumonia
- A deteriorating course that may
eventually lead to respiratory failure
 Contraindication
- Total upper airway obstruction
(which require surgical airway)
- Total loss of facial/oropharyngeal
landmarks
- Anticipated difficult airway
(mallampati III or IV)
NASOGASTRIC (NG) TUBE
 Indication
 Therapeutic
- Gastric decompression in intestinal
obstruction or post GI surgery
- Gastric lavage following ingestion of
poison or drug overdose
- Administration of feeds, fluids and
medications
 Principles of Pediatrics by Adeleke

O Retinoblastoma, 150
Opsoclonus-myoclonus-ataxia syndrome, Ringers lactate, 10
147 Rifampin, 94
Osmolality, 9 Rituximab, 137
Overfill hypothesis, 123 Rolandic epilepsy, 55

P S
Pathological jaundice, 20
Paradoxical embolism, 67
Paratracheal lymphadenopathy, 89
Partial seizure, 52
Passive Immunity, 160
Patent Ductus Arteriosus, 68
Pediatric-Modified Rifle Criteria, 118
Pencil-point sign, 96
Pentavalent vaccine, 161
Persistent diarrhea, 99
Persistent pulmonary hypertension of
newborn, 50
Phototherapy, 23-25
Physiological jaundice, 19
Pneumonitis, 80
Pneumatocele, 85
Prednisone, 125
Priampism, 130
Primary nephrotic syndrome, 122
Pulmonary tuberculosis, 88
Pyrazinamide, 94
Q Subacute osteomyelitis, 152
Quinine, 143
Quantitative Buffy Coat, 140
R Total Anomalous Pulmonary Venous Return,
Rasburicase, 136
Refeeding Syndrome, 112-113
Renal biopsy, 116, 119, 125
Respiratory distress syndrome, 47-48
ReSoMal, 111
Saucerization, 155
Sequestration crisis, 130
Sequestrum, 153, 154
Sequestrectomy, 155
Severe Acute Malnutrition, 106
Severe malaria, 141
Severe wasting, 106
Shakir tape, 8
Sickle cell habitus, 128
Simple febrile seizure, 62
Simple febrile seizure plus, 64
Small for gestational age, 41
Spastic cerebral palsy, 58
Spontaneous bacterial peritonitis, 124
Sporadic Burkitt lymphoma, 133
Sporozoites, 139
Stadiometer, 5, 6
Starry sky appearance, 135
Status epilepticus, 56
Stem cell transplantation, 132
Steeple sign, 96
Steroid resistance, 125
T
Thin and Thick blood film, 140
71
Toxoids, 160
Transient tachypnea of the newborn, 49
Transposition of Great Arteries, 72
Trophic feeding, 44

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 Principles of Pediatrics by Adeleke

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