Professional Documents
Culture Documents
Junior Paediatrics Notes 3rd Year
Junior Paediatrics Notes 3rd Year
Junior Paediatrics Notes 3rd Year
** Identify special needs children. Provide or facilitate access to other health or community services where
possible
Note: In Jamaica the MOH recommends a minimum of 10 well child visits over the first 2 years of life
Prenatal Visit
** For the prenatal visit the following persons should attend:
- First time parent
- High risk mothers
- Those who request a conference
Newborn Visit
** Full clinical examination including:
- Anthropometry
- Systemic examination
** Hepatitis B vaccine and IG to positive mothers
** General discussion:
- Development
- Feeding
- Bowel movements
- Skin care
- Safety
Development
** Typical children follow a trajectory of increasing physical size and increasing complexity of function
- The child triples his/her birth weight within the first year
Fine Motor
- Follows slow-moving objects
- Looks and responds to faces
- Grasping skills
** The grasp begins as a raking motion involving the ulnar aspect of the hand at age 3-4 months.
- The thumb is added to this motion at age 5 months
- The thumb opposes the fingers for picking up objects by age 7 months
- Neat pincer grasp emerges at about age 9 months
- Children should not have a significant hand preference before 1 year of age and typically develop
handedness between 18 and 30 months
Language
- Cries, makes some response to sound
Social Development
- Recognizes familiar voices
- Calms to high-pitched, soft voice; quiets to gentle touch
Primitive Reflexes
- Root, suck, moro, grasp
Feeding
** Provide advice for breastfeeding
** If the mother is using formula they should use one that is:
- Iron fortified
- Offer as much as your baby will take
- Feed whenever your baby signals
- Do not warm bottles in the microwave oven
** Pacifiers are generally unnecessary. Do not give honey during the baby’s first year
Do not give honey because of the possibility of botulinum toxin from bees
- Do not use recreational drugs or cigarettes
Bowel Movements
1- Meconium- sticky, tarry black stools
- Are the earliest stools of an infant
- Unlike later feces, Meconium is composed of materials ingested during the time the fetus spends in the
uterus
- Contains intestinal epithelial cells, mucus, amniotic fluid, bile and water
- Meconium is almost sterile unlike later feces
- Viscous and sticky like tar and has no odor
- Should be completely passed by the end of the first few days of post-partum life 3-4 days for trasitinal
- Note: Hirschsprung’s disease presents as a failure to pass Meconium stool
2- Breast milk stools- are usually yellow, seedy, runny and have a musty odor
- Breastfed babies may have frequent bowel movements
- May have a movement after every feed
3- Formula fed stools- are pastier than those of breastfed babies. Sometimes have firmer or less frequent
stools
- If hard, pebble-like stools or significant pain with stooling or absence of stool in five days contact a
doctor for advice
Skin Care
** Newborn babies’ skin often will peel or flake. This is a natural process and is a part of the newborn’s
adjustment to life in the open air
- No special lotions or oils are needed
Discharge
** If discharge is considered before 48 hrs it should be limited to infants who are of singleton birth between 38
and 42 weeks gestation
- These neonates should be of birth weight appropriate for gestational age
1- The antepartum, intrapartum and postpartum courses for mother and infant are uncomplicated
2- Vaginal delivery
3- The infant’s vital signs are documented as being with normal ranges and stable for the last 12 hrs
preceding discharge
- Respiratory rate below 60 breaths/min
- Heart rate of 100-160 beats/min
- Axillary temperature of 36.5 deg C – 37.4 deg C
5- The infant has completed at least two successful feedings with documentation that the infant is able to
co-ordinate sucking, swallowing and breathing while feeding
7- The clinical significance of jaundice, if present before discharge, has been determined Continued presence is a poor
prognostic sign
8- Maternal and infant blood test results are available and have been reviewed, including:
- Maternal syphilis and hepatitis B surface antigen status
- Cord or infant blood-type and direct Coomb’s test results
- Screening tests performed (eg HIV)
** The infant should be scheduled for a follow up visit with a physician if being discharged before 48 hrs. The
purpose of the follow-up visit is to: Know this for exam. It's easy.
- Weight the infant and assess the general health, hydration and degree of jaundice
- Review feeding pattern and technique including observation of breastfeeding
- Assess quality of mother-infant interaction
- Reinforce maternal or family education in infant care
- Review the outstanding results of lab tests performed prior to discharge
- Verify the plan for health care maintenance including well-baby visits, immunizations, etc
By 1- Month Visit
- Ensure that the family is adjusting to the new addition
- Feeding routines established
- Sleeping routine established
- Identify the at risk mother
Gross Motor:
- Developing better head control
- Able to lift head off the bed when lying on stomach
Fine Motor:
- Still has automatic grasp reflex when objects touch his or her hand
Language:
- May be developing different cries for pain, hunger and fatigue
Social:
- Watches and quiets when others speak to infant
- Opens and closes mouth as others speak
Colds
** If a cold develops:
- Elevate the head of the crib
- Run a cool-mist vaporizer
- Use an infant bulb syringe to gently suction mucus from the nose. Normal saline drops also help to
loosen the mucus
- Seek medical attention if the baby has a rectal temperature of 100.4 F (38C) or higher or is coughing
frequently, or refusing to eat
2-Month Visit
** Full clinical examination and developmental milestones
- Immunization
- DPT so loses
- Polio 4 doses + bosterbooster
- Hib 4 doses including birth if tire
mother
doses
- Rotavirus 3
-
ketosis Prevnar- vaccine against pneumoccal bacteria (streptococcus pneumoniae)
- Health promotion (nutrition, sleep, stimulation)
Gross Motor:
- Holds head in midline and lifts chest off the table
Fine Motor
- No longer clenches fist tightly
Speech:
- Coos
Social
- Reaches for familiar people or objects and anticipates feeding
4-Month Visit
Gross Motor:
- Rolls over
- Supports on wrists and shifts weight
Fine motor
- Reaches with arms in unison, brings hands to the midline
Speech:
- Laughs, orients to voice
Social:
- Enjoys looking around
Sleep:
- Wide variation in night sleep patterns
- Some infant sleep 8 or more hours, others 4-6 some wake every 3hrs
Nutrition:
- Breastfed and formula fed infants do not need solid foods until 6 months
** Signs of readiness for solid food include trying to sit up and showing interest in watching others eat
** The first goal of eating solid foods is simply to learn the new skill. The best time to feed the baby solids is
often in the mid-morning
- Start with rice cereal once a day Because Rice is the least allogeneic of the cereals. So start with it first.
- One or two tablespoons
- Allow one new food every week
- After cereals, add single fruits and vegetables that have been pureed
- Gradually increase solid food meals to 2-3 times daily over the next few months
- If the baby dislikes the taste of a food the first time it is offered, you can try again later
6-Month Visit
Gross Motor:
- Sits unsupported
- Puts feet in mouth when lying supine
Fine Motor
- Unilateral reach
- Using raking grasp
- Transfers objects
Speech
- Babbles
- Lateral orientation to bell
Social:
- Recognizes that someone is a stranger
Nutrition
- Begin using a cup for water
- Juice is not necessary. If given limit to no more than 4 oz per day
- Add rice cereal, pureed fruits and vegetables
Sleep:
- Encourage the use of transitional object
- Sleep routine
- Discourage 3 hourly feedings
Toys:
- put in, take out toys
- Noisy toys
- Stacking toys
Teeth
- The first teeth can appear at any time from about 4-12 months First permanent teeth to erupt are the First Molars
- Baby may become irritable First primary teeth to erupt are the bottom Central Incisors
- Offer your baby something to chew on
- Occasionally teething gels or acetaminophen may be soothing
- Keep the teeth clean by wiping daily with a cloth, gauze or toothbrush
9-Month Visit
Gross Development:
- Pivots when sitting, crawls well, pulls to stand, crusies
Fine Development:
- Uses immature pincer grasp
- Probes with forefinger
- Holds bottle, throws object
Speech
- “Mama” Dada indiscriminately, waves bye-bye, gestures, understands NO
Social
- Starts exploring environment
- Plays gesture games
Note: Wait until your child is 12 months old to introduce whole cow’s milk
1-Year Visit
** Immunization: MMR and varicella
Gross Motor:
- Walks alone
Fine Motor:
- Uses mature pincer, can make crayon marks
Speech:
- Uses 2 words other than mama/dada, follows one step commands with gestures
Social:
Imitates actions, comes when called, co-operates with dressing
15-Month Visit
** Immunization- Hib booster
Gross Motor-
- Creeps upstairs, walks backwards independently
Fine Motor
- Scribbles in imitation, builds tower of 2 in imitation
Speech
- Uses 4-6 words
- Follows 1 step command without gesture
Social
- Uses cup and spoon
18-Month Visit
** Boosters: DPT and polio
Gross Motor:
- Runs, throws object from standing without falling
Fine Motor
- Scribbles spontaneously, build tower of 3, scribbles spontaneously
Speech
- Two word phrases, understands 2 step commands
Social
- Mimics parents
2-Year Visit
Developmental Milestones
Clinical examination
Toilet Training
** Many children train themselves with little encouragement by 3 years. To become toilet trained children
require the following skills:
i- Motor Skills- stand, sit and walk unaided
ii- Verbal skills- to express needs
iii- Social skills- uncomfortable when messy
iv- Sensory skills- retain a full bladder/rectum
Teeth
- Before the emergence of teeth, clean the oral cavity with a soft washcloth and water
- No toothpaste under the age of two, the mechanical action of brushing with a soft toothbrush is
sufficient
- Supervise brushing of teeth up to age 8-10
- Use a pea sized amount of toothpaste
- Floss children’s teeth
- 6 monthly visits to dentist
- First dental visit at age 2 years
Adolescent Issues
Home
- Household composition
- Family dynamics and relationships
- Living and sleeping arrangements
- Guns in the home
Education
- School attendance
- School performance
- Goals for the future
Activities
- Friends with same and opposite sex
- Dating
- Recreational activities
Drugs
Sexuality
- Sexual feelings towards same or opposite sex
- Partners, use of contraception, history of STD’s abortions
Physical Exam
- Anthropometry
- Dentition/gums
- Skin
- Thyroid
- Spine
- Breasts
- External genitalia
- Pelvic
- Immunization: HPV, Menningococcal
2. Immunization- GOODEN 14-11-10
Immunization- is a method of preventing disease by administering vaccines
** There are two wars in which vaccines confer immunity:
i- Active immunization- is the process by which the immune system is stimulated to produce Antigen is given
memory for a particular disease after inoculation with the organism or part of the organism
- EX: Tetanus toxoid, diptheria toxin
- Live attenuated vaccines induce active immunity
- Immunity is usually lifelong with live vaccines
- BUT boosters are required for killed vaccines
ii- Passive immunization- is achieved by direct administration of preformed antibodies or Antibody is given
specific immune globulins
- Given to a patient who is immunocompromised
- Or in the case of post-exposure prophylaxis where there would be insufficient time to build up
natural immunity
Vaccination- is the main method of producing effective immunity for a number of communicable diseases
Vaccine Info:
- Names of vaccines
- Dose and Route of administration
- Storage/cold chain
- Side effects
- Contraindications MINISTRY OF HEALTH - JAMAICA
- Mandatory vaccines (Ministry of Health)
IMMUNIZATION SCHEDULE FOR CHILDREN
- Other vaccines
Vaccines are listed under the routinely recommended ages. Shaded bars indicate range of acceptable ages for vaccination
AGE
VACCINE BIRTH 6 WEEKS 3 MONTHS 6 MONTHS 12 MONTHS 18 MONTHS 4-6 YEARS
BCG
BCG BCG
Polio
OPV / IPV OPV / IPV OPV / IPV OPV / IPV OPV / IPV OPV /IPV
Diphtheria
Pertussis, DPT / DT DPT / DT
Tetanus (DPT)
Or Diphtheria
Tetanus (DT)
Measles
Mumps MMR
Rubella MMR MMR
(MMR)
Sponsored by PAHO/WHO
Immunizations are given close to each other because they all cause febrile states. Having one or close febrile states prevents discomfort.
Immunization Goals- Jamaica
- Vaccination of all children 0-11 months with BCG, DPT/HBV/HIB, MMR, Polio
- Full immunization of all children less than 7 years before school entry (Public Health Law)
- Immunization of antenatal clients to prevent neonatal tetanus
Vaccine Age
BCG At birth
DPT/Hib/HBV & OPV 6 weeks, 3 months, 6 months
DPT & OPV 18 months and 3-6 years
MMR 12 months, 4-5 years and females of reproductive age 18 months
DT Pregnancy
BCG
¥
** Bacille Calmette-Guerin vaccine (BCG) consists of live attenuated Mycobacterium bovis
- Given to prevent tuberculosis
0.05mL
Dose: 0.1 mL intradermally in right deltoid area
THERE IS NO FEVER IN BCG
Storage Temp- 2.8 deg C
Age: from birth to 6 weeks
Side Effects:
- Fever
whoand swelling at the injection site
- Local ulceration/abscesses and regional lymph node enlargement
- Lupus vulgaris- are painful cutaneous tuberculosis skin lesions with nodular appearance
- Most often on the face around nose, eyelids, lips, cheeks and ears
- BCG adenitis- is the inflammation of local lymph nodes
Contraindications:
- Pregnant women
- Immunocompromised individuals- because it has caused disseminated or fatal infections
** BCG reduces the risk of tuberculous meningitis and disseminated TB in pediatric populations by 50-100%
- When given in the first month of life
DPT -
Intramuscular
DPT= Diptheria, whole cell pertussis, tetanus
DTaP- Diptheria, tetanus, acellular pertussis
- Killed vaccine
- Storage at 2-8 deg C
TT⇐IIÉ%
** Children > 7years use dT vaccine
awakened art
6 mitts apart
2 { 3 given
close
contraindicated
pertussis
If
neurological problem
Contraindications:
- Previous anaphylaxis to this vaccine or any of its components
- Guillain Barre Syndrome within 6 weeks of previous dose
- Unstable or evolving neurological condition is contraindicated for the pertussis component
Guillian Barre Syndrome - Immune system attacks part of the peripheral nervous system. The first symptoms of this disorder include varying degrees of weakness or
tingling sensations in the legs. In many instances the symmetrical weakness and abnormal sensations spread to the arms and upper body.
Side Effects:
- Fever, redness and swelling at the injection site
- Fever > 40 deg C
- Persistent inconsolable crying lasting more than 3 hours
- Hypotensive, hyporesponsive episode ✓
- Seizures
- Side effects can occur within 48 hrs of vaccinations
Pertussis
** Bordatella pertussis is a highly communicable pathogen that causes whooping cough.
- After incubation period of about 2 weeks, the catarrhal stage develops with mild coughing and
sneezing
- During the paroxysmal stage the cough develops its explosive character and the characteristic whoop
on inhalation
- This leads to rapid exhaustion and may be associated with vomiting, cyanosis and convulsions
- Major complications occur mostly in infants
- Every infant should receive 3 injections of pertussis vaccine during the first year of life followed by a
booster series for a total of 5 doses
- Note: Prophylactic administration of erythromycin for 5 days may also benefit unimmunized infants
or heavily exposed adults
** The DTaP (acellular vaccine) has an improved safety profile with decreased risk of side effects
- Crying, high fever, seizure <1%
- Shock, seizure, coma <0.003%
** The toxin is absorbed into the mucus membranes and causes destruction of epithelium and a superficial
inflammatory response
- The necrotic epithelium becomes embedded in exuding fibrin and red and white blood cells
- This forms a grayish pseudomembrane over the tonsils, pharynx or larynx
- Any attempt to remove the membrane exposes and tears the capillaries resulting in bleeding
- The diptheria bacilli within the membrane continue to produce toxin, which is absorbed and may result
in toxic injury to heart muscle, liver, kidneys and adrenals
- The toxin also produces neuritis resulting in paralysis of the soft palate, eye muscles or extremities
Note: Death may occur as a result of respiratory obstruction or toxemia and circulatory collapse
** Diptheria can affect the immunized, partially immunized and un-immunized persons
- Waning immunity in adolescents and adults
Polio
** Poliovirus infection is subclinical in 90-95% of cases. It causes non-specific febrile illness in about 5% of
cases and aseptic meningitis
- Paralytic disease 1-3%
- 1992 was the last indigenous case from CAREC member country
- Epidemic polio in Hispaniola
- Mutation from polio Type I virus in Sabin OPV OPV = Oral Polio Vaccine
- Mutation through serial passage of vaccine-virus in non-immunized persons
- Happened before in Egypt and China
** The initial symptoms are fever, myalgia, sore throat and headache for 2-6 days
- Mild cases resolve completely
- In only 1-2% of these children does high fever, severe myalgia and anxiety portend progression to loss
of reflexes and subsequent flaccid paralysis
- Sensation remains intact
- However hyperaesthesia of the skin overlying paralyzed muscles is common and pathogonomic
- Paralysis is usually asymmetrical
- Proximal limb muscles are more often involved than distal
- Bulbar involvement affects swallowing, speech and cardio respiratory function
- Bladder distention and marked constipation usually accompanies lower limb paralysis
Note: Aseptic meningitis due to poliovirus is indistinguishable from that due to other viruses
- Paralytic disease in the USA is usually due to non-polio enteroviruses
- Polio may resemble Guillain-Barre syndrome, polyneuritis, tick paralysis
Treatment: Supportive
- Bed rest, fever and pain control
- No intramuscular injections should be given in the acute phase
** In the USA there has been no wild-type polio for more than 20 years
- 1 in 2.4 million risk of vaccine associated polio with the use of OPV
- BUT the OPV is more effective in developing herd immunity than the IPV
Contraindications:
- Previous anaphylaxis to this vaccine or its components
- OPV should not be given to those who are immunosuppressed
Side Effects:
- Fever, redness and swelling at injection site
- Loose stools
- Vaccine associated polio- rarely with OPV only
Contraindications:
- Previous anaphylaxis to this vaccine or to neomycin, which is one of its components
- Severe immunodeficiency
- Egg allergy IS NOT LONGER A PRECAUTION ’ eggs -
Canadian Journal of Diseases 1996 Egg allergy and MMR vaccine: New
recommendations from the National Advisory Committee on Immunization
Side Effects:
- Develop 7-12 days after immunization
- Fever, redness and swelling at the site
- Transient rash
- Encephalitis (rarely)
- Transient thrombocytopenia
Measles
** The attack rate in susceptible individuals is extremely high. Spread is via respiratory droplets
- High fever and lethargy
- Sneezing, eyelid edema, tearing, cough, photophobia, coryza (acute rhinitis)
- Koplik spots are white, macular lesions on the buccal mucosa usually opposite the lower molars
- Discrete maculopapular rash begins when the respiratory symptoms are maximal
- The rash spreads quickly over the face and trunk and coalesce to a bright red
- Lymphopenia is a characteristic finding
- Vaccination prevents the disease in susceptible exposed individuals if given within 72 hrs
Note: The MMR vaccine is contraindicated in pregnant women and women intending to become pregnant in
the next 28 days
- Also contraindicated in immunocompromised persons
- EXCEPT those with asymptomatic HIV with age specific CD4 lymphocyte counts
- Also contraindicated in children receiving high dose corticosteroid therapy (>2mg.kg/day or 20mg/day
total, for longer than 14 days
Rubella
** Aerosolized respiratory secretions transmit rubella
- Patients are infectious 5 days before until 5 days after the rash
- Congenital rubella usually follows maternal infection in the first trimester
** Young children may only have a rash. Older patients have a non-specific prodrome of low-grade fever,
ocular pain, sore throat and myalgia
- Post auricular and suboccipital adenopathy is characteristic
- The rash consists of erythematosus discrete maculopapules beginning on the face
- Rash spreads quickly to the trunk and extremities
** Congenital infection has more serious consequences. The main manifestations are:
i- Growth Retardation- between 50-85% of infants are small at birth
ii- Cardiac anomalies- pulmonary artery stenosis, patent ductus arteriosus, ventricular septal defect
iii- Ocular anomalies- cataracts, micropthalmia, glaucoma, retinitis
iv- Deafness- sensorineural in >50%
v- Cerebral disorders- chronic encephalitis, retardation
vi- Hematological disorders- thrombocytopenia, dermal nests of extramedullary hematopoiesis,
lymphopenia
vii- Others- hepatitis, osteomyelitis, immune disorders, malabsorption, diabetes
Note: Congenital infection is associated with low platelet counts, abnormal LFTs, hemolytic anemia and very
high rubella IgM antibody titers
l
-
Note: Congenital rubella must be differentiated from congenital CMV infection, toxoplasmosis and syphilis
Rotavirus
** Rotavirus accounts for 45% of severe diarrhea in infants and children worldwide
- Oral tetravalent rotavirus vaccine (RRV-TV) was recommended
- July 1999 was associated with increased risk of intussusception = an instance of the inversion of one portion of the intestine within another
Storage at 0 deg C
Dosage: oral route (2 mls)
- Rotarix- give 2 doses (6 weeks to 6 months) Rix 266
)
Side Effects:
- Diarrhea and vomiting
- Irritability
- Nasopharyngitis
- Bronchiolitis
- RARE: intussusception
Contraindications:
- Previous anaphylaxis to this vaccine or any of its components
- Precaution in immunocompromised host or children with chronic GI illnesses
- Infants transfused with blood products or immunoglobulins within 6 weeks
Influenza
** Symptomatic infections of influenza are common in children because they lack immunologic experience
with influenza viruses
- Infection rates in children are greater than in adults
- Epidemics occur in the fall and winter
- Three main types of influenza viruses (A/H1N1, A/H3N2, B) cause most human epidemics
- Spread of influenza occurs via airborne respiratory secretions.
- Incubation periods is 2-7 days
- Attack rates of 10-40% in healthy children
- Hospitalization rates of 1%
- Pneumonia, croup, bronchiolitis- 0.20-0.25%
** The inactivated influenza vaccine has 3 virus strains (Type A-2, B-1)
** The following persons should receive an influenza vaccine:
- Asthma
- Chronic lung disease
- Cardiac disease
- Immunosuppression
- HIV
- Sickle cell anemia
- Chronic renal disease
- Long term aspirin use
- Diabetes
- Late pregnancy
- Health care personnel
- Persons less than 6 months
-
Contraindications:
- Allergy to egg or neomycin
- Prior history of Guillan Barre Syndrome
Adverse Effects
- Local reactions
- Mild fever
- Guillain Barre syndrome
- Anaphylaxis- due to allergy to egg or chicken protein
H. influenzae B
** 40% of cases occur in children younger than 6 months who are too young to have completed a primary
immunization series
E--
vomiting and a high pitched cry
2- Bacteremia/Septicemia
3- Epiglottitis (supraglottic croup)- evidence of dysphagia, characterized by a refusal to eat or swallow
saliva and drooling.
- This finding along with a high fever in a toxic child should strongly suggest the diagnosis and lead to
prompt intubation
- The above signs are significant even without the classic cherry-red epiglottis on direct examination
- Note: Stridor is a late sign
4- Septic arthritis- Hib is a common cause of septic arthritis in unimmunized children younger than 4
years
- Child is febrile and refuses to move the involved joint and limb
- Examination reveals swelling, warmth, redness, tenderness on palpation and severe pain when
movement is attempted
** Four separate carbohydrate protein conjugate Hib vaccines are currently available
- HibTITER
- PedvaxHIB
- ActHIB
- ProHIBIT
Contraindications: Should not be given to anyone who has had a severe allergic reaction to a prior vaccine
dose
- Should not be given to infants before 6 weeks of age
** Given at 2, 4, 6 months and a booster at 15 months
Side Effects: Local pain, redness and swelling in 25% of cases
- Systemic reactions such as fever and irritability are rare
Treatment- All patients with bacteremic Hib disease require hospitalization for treatment
- Use third generation cephalosporins to treat (cefotaxime or ceftriaxone)
- Meropenem is an alternate choice
Note: In addition to antibiotics children with Hib meningitis should be given dexamethasone immediately after
diagnosis
- The steroid continued for 4 days may reduce the incidence of hearing loss in children with Hib
meningitis
- Dosage: 0.6 mg/kg/day in 4 divided doses for 4 days
Streptococcus Pneumoniae
** Streptococcus pneumoniae is the most common cause of invasive bacterial infection in children
- Vaccine is given as a 0.5 mL IM dose
- 2, 4, 6 and 15 months (booster) for 7 valent
- Booster at 4 years for the 23 valent
- Killed vaccine
- 23 valent polysaccharide vaccine or 7 valent protein conjugate vaccine
- Storage at 2-8 deg C
- Especially important for patients with sickle cell disease
Contraindications: Individuals who suffered a severe allergic reaction such as anaphylaxis after a previous
vaccine dose
- Vaccination should be deferred during moderate or severe acute illness, with or without fever
- History of invasive pneumococcal disease is not a contraindication to vaccination
Note: Pneumonia is the most common cause of death in the developing world
- S. pneumoniae accounts for 70% of pneumonias and 25% all cause mortality in developing counties
- Worldwide increase in drug-resistance
** Polysaccharide Pneumococcal Vaccine (23PS)- Single dose of 23PS given to ALL children 24-59 months
old regardless of risk of pneumococcal illnesses
- In Jamaica given to sicklers, functional or anatomic asplenia or other immunodeficiency
Meningococcus
** Meningococcal vaccination is a tetravalent meningococcal polysaccharide-protein conjugate
- Currently recommended for routine use in young adolescents (11-12 years), those entering high school
and college freshmen living in dorms
** Infections with Neisseria meningitides can cause significant mortality and morbidity
- Meningococcal disease has a case fatality rate of 10-14% even when treated
- 19% of survivors are left with serious disabilities
- Ex: neurologic deficits, loss of limbs or limb function, hearing loss
Contraindications: Anyone with a severe allergic reaction to any component of the vaccine
- This includes allergy to diptheria toxoid and rubber latex
- Contraindicated in persons with prior history of Guillain Barre Syndrome
- Can be given to immunosuppressed individuals
** Close contacts of a patient with invasive meningococcal disease should receive antimicrobial prophylaxis
to prevent spread of disease
- Ideally within 24 hrs of exposure
Complications:
** Secondary bacterial infection with staphylococci or group A streptococci is most common Reye's (Ryes) syndrome - rare but serious condition
that causes swelling in the liver and brain. Most often
- Protracted vomiting or a change in sensorium suggests Reye syndrome or encephalitis affects children and teenagers recovering from a viral
infection, most commonly the flu or chickenpox.
- Reye syndrome would be seen in patients who were using salicylates
- Encephalitis usually involves cerebellitis with ataxia
** Neonates born to mothers who develop varicella from 5 days before to 2 days after delivery are at high risk
for severe or fatal disease
- These neonates should be given varicella-zoster immune globulin
** Varicella during the first 20 weeks of pregnancy may cause congenital infections
- Associated with cicatricial skin lesions, limb anomalies and cortical atrophy
Note: Unusual complications of varicella include optic neuritis, myocarditis, transverse myelitis, Orchitis,
arthritis
Dosage: Two doses of VAR vaccine are recommended for immunization of all healthy children aged 12 months
and older
- Also for adolescents and adults without evidence of immunity
- VAR can be given simultaneously with MMR at separate sites
Contraindications: Severe allergic reaction after a previous vaccine dose or to a vaccine component
- VAR and MMRV are live-virus vaccines therefore they are contraindicated in children with cellular
immunodeficiencies
- EX: leukemia, lymphoma, congenital T-cell abnormalities
- EXCEPTION: Can be given to HIV-infected children who are not severely immunosuppressed
- Contraindicated in children receiving immunosuppressive therapy including high-dose steroids
- Should not be given to pregnant women BUT can be given to children living with pregnant women in
their household
** Indicated for children as young as 6 months traveling to endemic areas or to countries that require it for
entry
- Otherwise immunization should be delayed until 9 months or older Baby 69
** Yellow fever vaccine is a live attenuated vaccine made from 17D yellow fever attenuated virus strain
grown in chick embryos
- Protects for 10 years
- Given as a single subcutaneous injection of 0.5 mL
Contraindications:
- Infants younger than 6 months due to increased susceptibility to vaccine associated encephalitis
- Anaphylactic egg allergy
- Immunocompromised individuals
- Persons with a history of thymus disease
Adverse Reactions: Mild usually low grade fever, mild headache and myalgia
- Serious adverse reaction syndrome is vaccine associated viscerotropic disease, consists of severe
multiple organ system failure and death within 1-2 weeks post vaccination
Cholera Vaccine
** New oral vaccines are highly effective against Vibrio cholerae
- Does not prevent unapparent infection or introduction of organism into the country
- Do not give vaccine to close contacts
- Vaccine cannot control spread of cholera
** Given as 2 doses one week apart. Has an 85% vaccine efficacy against V. cholerae in the first 6 months
- Greater than 50% cross protection against enterotoxigenic E. coli diarrhea
Hepatitis A
** Accounts for symptomatic hepatitis in 30% of children
- Symptomatic in most older children and adults with jaundice in 70%
- Prolonged, relapsing for > six months
- Fulminant hepatitis, underlying liver disease
- Fecal-oral transmission
** Most hepatitis A infections occur in individuals without known risk factors for the disease
- More than 50% of all infections are thought to occur in children
- Children are more likely than adults to be asymptomatic while infected
- Therefore they are often the mechanism by which hepatitis A is spread through households and
communities
1
- Mild pain and induration at injection site
Hepatitis B
** Hepatitis B vaccine is a recombinant DNA vaccine
- Stored at 2-8 deg C
Contraindications:
- Previous anaphylaxis to this vaccine or any of its components
- Including a serious allergy to yeast
- Pregnancy is NOT a contraindication to vaccination
Side Effects:
- Fever, redness and swelling at the injection site
Human Papilloma Virus
** Approximately 70% of cervical cancers are caused by the high cancer risk types 16 and 18
- Over 90% of genital warts are caused by the low cancer risk types 6 and 11
** The quadrivalent HPV vaccine types 6, 11, 16 and 18 was licensed for use in females aged 9-26 years for
the prevention of the following:
- HPV-related cervical cancer
- Cervical cancer precursors
- Vaginal and Vulval cancer precursors
- Anogenital warts
Contraindications:
- Previous anaphylaxis to the vaccine
- History of anaphylaxis to yeast
- Pregnancy
Side Effects:
- Fever, redness and swelling at the injection site
- Myalgia, dizziness and headaches
- Post marketing reports of syncope have been reported after vaccination so vaccine recipients should be
observed for 15 mins after vaccination
Cold Chain
** To ensure the efficacy of the vaccines, certain guidelines that govern storage, handling and transport of the
vaccines must be adhered to
** Diluent and vaccine must be collected from the airport as soon as they arrive
- Transported at the correct temperature from one storage site to another
- Stored at the correct temperature at the central, parish and health center levels
- Transported at the correct temperature to outreach sites
- Kept cold during immunization sessions
3. The Infant or Child with Fever
A mother brings a 10-month-old male infant to casualty, with a complaint that he has been having fever
for the past 5 days. The fever is intermittent and worse at night. She used a thermometer at home and the
highest temperature recorded was 39.8 0 C. She tried sponging the infant with cold water, but he began
shivering. His appetite has been decreased and he is irritable.
a) How would you determine if this child has fever? What factors affect body temperature?
** The core temperature of the deep tissues of the body remains constant (within +/- 1 deg F)
- Except when a person develops a febrile illness
** The skin temperature however rises and falls with the temperature of the surroundings
Note: The average normal core temperature is usually between 98- 98.6 deg F when measured orally and about
1 deg F higher when measured rectally
Heat Production
- Basal rate of metabolism of all the cells in the body
- Extra rate of metabolism caused by muscle activity (includes muscles contractions caused by
shivering)
- Extra metabolism caused by the effect of thyroxine on the cells (testosterone and growth hormone)
- Extra metabolism caused by the effect on epinephrine, norepinephrine and sympathetic stimulation on
the cells.
- Extra metabolism caused by increased chemical activity in the cells, especially when the cell
temperature increases
- Extra metabolism needed for digestion, absorption and storage of food (thermogenic effect of food)
Note: Therefore most of the heat produced in the body is generate in the deep organs
- Especially the liver, brain, and heart and skeletal muscles during exercise
- The heat is transferred from the deeper tissues to the skin and then is lost to the air
** Blood vessels are distributed beneath the skin. A high rate of skin flow causes heat to be conducted from the
core of the body to the skin
- Therefore by controlling blood flow within plexuses beneath the skin through vasoconstriction and
vasodilation it can act as an effective mechanism for heat transfer from the body core to the skin
- The vasoconstriction is controlled mostly by the sympathetic nervous system om response to changes
in body core temperature and changes in environmental temperature
** The clothes a person is wearing can affect body temperature. This is because clothing entraps air next to the
skin and decreases the flow of convection air currents
- Therefore the rate of heat loss from the body by conduction and convection decreases
** Stimulation of the anterior hypothalamus (preoptic area) by excess heat causes sweating
- The nerve impulses from this area that cause sweating are transmitted in the autonomic pathways to the
spinal cor
- Then through sympathetic outflow to the skin everywhere in the body
- Sweat is produced from sweat glands and evaporation of the sweat removes heat from the body
** Body temperature is regulated by nervous feedback mechanism. Most of these mechanism functions
through temperature regulating centers in the hypothalamus
- Cold and hot receptors are found throughout out the body and these help to elicit the reflex regulation
responses
** To determine if a child has a fever begin with the history. Elicit from parents information duration of fever,
how the temperature was taken, maximum height of fever documented at home
- All associated symptoms
- Chronic medical conditions and any medications taken
- Fluid intake and urine output
- Exposures and travel
** Document temperature, heart rate, respiratory rate and blood pressure as well as oxygen saturation
Change in general appearance (eg, toxic, lethargic)
Head - Bulging or sunken fontanelle in young children
Eyes - Discharge, pupil size
Ears - Signs of ear infection (loss of light reflect, bulging, red and immobile tympanic membrane)
Nose - Discharge
Mouth - Dry mucus membrane or lesions
Throat - Erythema, exudates, lesions
Neck - Meningeal irritation or adenopathy
Heart - Murmur, rubs, tachycardia, bradycardia
Lungs - Abnormal lung sounds, such as wheezing, rhonchi, or rales
Abdomen - Rigidity, guarding, abnormal bowel sounds
Genitals - Rash, discharge
Neurologic status - Not consolable, lethargic
Extremities - Signs of osteomyelitis, cellulitis, septic arthritis (pseudoparalysis)
Skin - Rash (especially petechial rash), cellulitis, abscess, omphalitis
** Perform a complete physical examination including a neurologic exam. Pay attention to the child’s degree
of toxicity and hydration status
c) How does the body produce fever? (Be prepared to explain this process to parents and colleagues.)
** Fever is defined as a body temperature above the usual range of normal.
- Can be caused by abnormalities of the brain itself or by toxic substances that affect the temperature-
regulating centers
** Fever occurs when there is a rise in the hypothalamic set point in response to endogenously produced
Pyrogens
** Causes of fever include:
- Infections
- Malignancies
- Autoimmune diseases
- Metabolic diseases
- Chronic inflammatory conditions
- Medications- including immunizations
- CNS abnormalities
- Exposure to excessive environmental heat
** Many proteins, breakdown products of proteins, lipopolysaccharide toxins released from bacterial cell
membranes, can cause the set point of the hypothalamic thermostat to rise
- Substances that cause this effect are called Pyrogens
- When the set point of the hypothalamic temperature regulating center becomes higher than normal, all
the mechanisms for raising the body temperature
d) What other causes of elevated body temperature exists and how do they differ from true fever?
** Other causes of elevated body temperature include dehydration
- Over-bundled with clothes in a relatively warm environment
** True fever is defined as an increase in body temperature due to an elevation of the thermal set point in the
anterior hypothalamus secondary to the release of Pyrogens
** With hyperthermic conditions other than true fever, the hypothalamic set point is not adjusted
- Therefore a fever occurs when the body sets the core temperature to a higher temperature, through the
action of the anterior hypothalamus
- However hyperthermia occurs when the body temperature is raised without the consent of heat control
centers
** Non-febrile hyperthermia occurs when heat gain exceeds heat loss such as with:
- Inadequate heat dissipation
- Exercise
- Drugs- amphetamines, cocaine, SSRIs
- Environmental Causes
Note: In addition giving anti-pyretics can reduce true fever. These drugs have no benefit in the treatment of
hyperthermia
** Hot, dry skin is a typical sign of hyperthermia. Fever by contrast usually produces cool, damp skin
.
e) How do you classify fever?
Fever classification
Temperature in rectum,
Temperature in mouth Temperature under the arm
vagina, or ear
(oral temp.) (axillary temp.)
(core temp.)
Grade °C °F °C °F °C °F
low grade 38-39 100.0-102.2 37.2-38.2 99-100.8 36.8-37.8 98.4-100.2
moderate 39-40 102.2-104.0 38.2-39.2 100.8-102.6 37.8-38.8 100.2-102
high-grade 40-41.1 104.0-106.0 39.2-40.3 102.6-104.6 38.8-39.9 102-104
hyperpyrexia >41.1 >106.0 >40.3 >104.6 >39.9 >104
iii- Remittent Fever- Temperature remains above normal throughout the day and fluctuates more than 1
deg C in 24 hrs
- EX: infective endocarditis
Different types of fever - Usually fever is differentiated with its mode of onset and character as:
Chronic - Slow, progressive and recurrent in nature; some people, even after recovering from typhoid, function as carriers
and suffer from it periodically.
Continuous fever - The temperature is continuous and variation is not more than 1°C and never touches normal in a whole
day.
Remittent - The temperature variation is more than 2°C and never touches the normal level in a whole day.
Intermittent - The fever is on and off and is only for a few hours and for the remaining period, the temperature will be
normal. Also, intermittent fever has been further classified as.
Contagious - The fever spreads easily from one to another, through droplet infection or by means of contacts, for example,
influenza, typhoid, chickenpox, smallpox, measles, dengue, mumps, plague, tuberculosis, jaundice and diphtheria
Non-contagious - The fever does not spread from one to another, for example, fever due to connective tissues, heart
problems, malignancy, trauma, fear, metabolic disorder like gout, milk fever, etc.
f) What information do you need to determine this infant’s problem? Explain why the information
would be necessary
Rigor is an episode of shivering or shaking followed by excessive sweating that follows a rapid increase in
body temperature
- Changes in appetite or behavior
Social History
- The environment the child lives in
- Who is the primary caregiver
- Contact with recent immigrants or persons who have traveled
- Exposure to homelessness and poverty
g) What other historical data would you elicit if the boy was less than one month old and older than 3
years old?
** If the child was less than a month old history from the mother is needed regarding the pregnancy and
delivery as well as the early neonatal life of the febrile neonate
- Typically infections that occur in the first week of life are secondary to vertical transmission
- Infections after the first week are usually community acquired
** The following factors are risk factors for serious bacterial infection in the neonate
- Birth weight of less than 2500 grams
- Rupture of membranes before the onset of labor
- Septic or traumatic delivery
- Fetal hypoxia
- Maternal peripartum infection
- Galactosemia
Information about the neonates nursery course should be noted, including the age at which the patient was
discharged from the nursery
- If circumcision was done or not
- Use of peripartum or antepartum antibiotics
- Diet and if formula fed hygiene surrounding bottle preparation
- Sleep histories
Note: Decreased oral intake or an acute change in sleep patterns may be clues to infection
h) What features in the examination would you elicit to rule out meningitis? How do the features
change with age?
Meningism is the triad of:
- Nuchal rigidity
- Photophobia
- Headache
** Signs of meningeal irritation. Inflammation or irritation of the meninges can lead to increased resistance to
passive flexion of the neck and the extended leg
- The corresponding signs are neck stiffness (nuchal rigidity) and Kernig’s sign
Kernig’s sign is positive when attempts to extend the knee are resisted by spasm, which is detected in the
hamstrings, and the other leg may flex at the hip and knee
Note: Kernig’s sign is not present in local causes of neck stiffness
- EX: cervical spine disease or raised intracranial pressure
** For bacterial meningitis, the younger the child, the less likely he/she is to exhibit the classic symptoms of
fever, headache and meningeal signs
** Children younger than 3 months have very non-specific symptoms including: hypothermia or hyperthermia,
change in sleeping or eating habits, irritability or lethargy, vomiting, high-pitched cry or seizures
** After age 3 months the child may display symptoms associated with bacterial meningitis:
- Fever, vomiting, irritability lethargy or any change in behavior
Note: Fontanelle bulging, diastasis of the sutures and nuchal rigidity point in meningitis in young infants but are
usually late findings
** After age 2-3 years children may complain of headache, stiff neck and photophobia
i) What are the common causes of fever in children less than one month old, 3-36 months old, older
than 3 years old?
j) What groups of children are considered high risk when they have fever?
** Febrile infants 28 days or younger have a high likelihood of serious disease including sepsis
- Children with incomplete immunizations or immunizations not up to date for age
- Immunocompromised children
- History of abuse and neglect
- History of chronic illness- cancer, diabetes
k) What investigations would you do? Do investigations vary with age? Explain why?
** A chest radiograph should be considered for neonates with signs of respiratory illness
- Coryza, cough, tachypnea, rales, rhonchi, nasal flaring or wheezing
** Lumbar puncture should be performed on the following children unless contraindicated
- Infants younger than 1 month
- All infants aged 1-3 months who appear unwell
- Infants aged 1-3 months with WBC less than 5 x 10 9 or > 15 x 10 9
- Febrile seizures
- Dehydration
- Shock
- Death
- Infections
- Malignancies
- Autoimmune diseases
- Metabolic diseases
- Chronic inflammatory conditions
- Medications- including immunizations
- CNS abnormalities
- Exposure to excessive environmental heat
http://emedicine.medscape.com/article/1609019-overview (READ)
http://emedicine.medscape.com/article/800286-followup
http://www.nice.org.uk/nicemedia/pdf/CG47Guidance.pdf
4. Febrile Child Tutorial
A 1-year-old boy was brought to casualty because he had the sudden occurrence of stiffness and then
jerking of his body, associated with upturning of his eyes and frothing at the mouth. This occurred about
15 minutes ago. Mom noted that he felt quite hot to touch, and she has been unable to communicate with
him.
a) What information would you need to obtain from his caregiver to determine the cause of his seizures?
Explain your reasons.
- The type of seizure and its duration, if seizures had occurred before
- History of fever, duration of fever and potential exposures to illness
- Presence of ill contacts
- History of recent travel or contact with travelers
- History of the cause of fever (viral illnesses, gastroenteritis)
- Recent antibiotic use- because partially treated meningitis should be considered
- History of seizures, neurologic problems, developmental delay or other potential causes of seizures
(trauma, ingestion of toxins)
- Family history of seizures
b) What features in the examination would help you to identify the cause of his problem?
** Search for the underlying cause of the fever
- Physical examination to find otitis media, pharyngitis or other signs of viral infection
- Serial evaluations of the patient’s neurologic status
- Check for meningeal signs
- Check for signs of trauma or toxic ingestion
d) How do you classify febrile seizures? Explain Simple febrile usually occurs between 6 months
and 5 years
1- Simple Febrile Seizures- generalized and last for <15 mins and do not recur within 24 hrs
2- Complex Febrile Seizures- are prolonged, recur more than once in 24 hrs or are focal
e) What are the risk factors for recurrence of febrile seizures? What is the risk of recurrence?
** One third of all children with a first febrile seizure experience recurrent seizures. Risk factors for recurrent
febrile seizures include:
- Young age at time of first febrile seizure
- Relatively low fever at time of first seizure
- Family history of a febrile seizure in a first degree relative
- Brief duration between fever onset and initial seizure
- Multiple initial febrile seizures during same episode
** Patients with all 4 risk factors have a grater than 70% chance of recurrence. Patients with no risk factors
have less than a 20% chance of recurrence
ABC
- Airway management
- High flow oxygen
- Anticonvulsants- benzodiazepines, phenytoin, Phenobarbital
- Antipyretics
** Children with febrile seizures have a slightly higher incidence of epilepsy compared with the general
population (2% vs 1%)
** Risk factors for epilepsy later in life include complex febrile seizure, family history of epilepsy or neurologic
abnormality and developmental delay
** Counsel about the link between family history and febrile seizures. The risk of a sibling developing febrile
seizure is 10% and almost 50% if the parent has had febrile seizures as well
** Parental anxiety and fear that their child may die or will develop brain damage should be addressed with
reassurance and education
** Risk of mortality associated with a simple febrile seizure is not increased
- Seizures that are complex occurred before the age of 1 year or were triggered by a temperature <39 deg C
were associated with a 2X increased mortality rate during the first 2 years after seizure occurrence
i) How often is a doctor likely to encounter this problem? What type of patient is likely to be seen with
this problem?
** Tend to occur in all races. Slight male predominance. By definition febrile seizures occur in children aged 3
months to 5 years
5. Arterial Blood Gases
** Blood test used to determine the:
- pH of the blood
- Partial pressure of carbon dioxide and oxygen
- Bicarbonate level
Oxygen Saturation
** Oxygen saturation is a measure of the amount of oxygen dissolved in a medium. Measures the percentage
of hemoglobin binding sites in the bloodstream occupied by oxygen.
- An oxygen saturation of under 90% indicates some degree of hypoxemia
pCO2
The part of the blood responsible for keep this balance is
the CO2 and HCO3. H2O + CO2 <-> H2CO3
Too much CO2 or too little H2CO3, the blood
will become acidic as in the case of HYPO-ventilation.
Too little CO2 or too much H2CO3, the blood will
become alkaline, as in the case of HYPER-ventilation.
6. Growth & Development- DR. PIERRE 12-01-10
Growth
- Formation of tissues
- Enlargement of head, trunk and limbs
- Progressive increase in strength and ability to control muscle groups
Development:
- Acquisition of functional skills
- Development of social relatedness, thought and language
- Emergence of personality
Growth Phases
Note: Inadequate weight gain during this period is known as failure to thrive
Failure to Thrive
** Failure to thrive is used to describe infants and young children whose weight curve has fallen off by two
major percentiles from a previously established rate of growth
- Therefore the term describes suboptimal weight gain in infants and toddlers
** Mild failure to thrive involves a fall across two centile lines there is no moderate failure to thrive
- Severe failure to thrive is a fall across three centile lines
Note: It may be difficult to differentiate the infant who is failing to thrive from a normal BUT small/thin baby
- Normal but short infants have no symptoms, are alert, responsive and happy and their associated
development is satisfactory
** Wasting- is the acute loss of weight or failure to gain weight at the expected rate that produces a condition
of reduced weight for height
** Stunting- is the reduction in height for age that is seen with more chronic malnutrition
5- Increased Requirements
- Thyrotoxicosis
- Cystic fibrosis
- Malignancy
- Chronic infection- HIV, immune deficiency disorders
- Congenital heart disease
- Chronic renal failure
Growth Assessment
** Requires the following:
- Equipment
- Technique
- Growth charts
- Interpretation
Percentile Concept
** Children of the same age will have different values for a particular parameter
Growth Monitoring
** Consists of measuring, recording and interpreting an individuals growth over a period of time
- Particularly important during periods of rapid growth
- Ex: neonatal period, infancy and childhood
- Commonly employed with young children in the first 5 years of life
- Intended to promote and sustain good health by detecting early growth failure
Note: Trends over time are more important than a single measurement
- Illness tends to restrict growth over an acute period
- Chronic low growth may be nutritionally related
Fetal Phase- Abnormal Growth
1- Intrauterine Growth Retardation- the baby is born full term but the baby is small and appears
malnourished
- May be due to severe maternal hypertension, poorly controlled diabetes, vascular disorders
(vasculitides), maternal smoking
- Note: Any condition that affects the vascularity of the placenta can lead to IUGR
- Maternal diabetes may cause IUGR because diabetes affects the vasculature of the placenta along with
his other effects on vessels in the body
** The IUGR infant has reduced glucose stores in the form of glycogen and body fat
2- Prematurity-
3- Large for Gestational Age- Infants of poorly controlled diabetic mellitus because the high
concentration of glucose in mother is transferred across the placenta
- Therefore the fetal pancreas undergoes hyperplasia and increases the production of insulin in the fetus
- Insulin is a growth hormone of fetal life and the fetus becomes larger
4- Familial- genetics
Development
** Process of acquisition of functional skills
Functional Areas
1- Gross Motor Cool Girls Feel Like Princesses
2- Fine Motor/Vision
3- Language/Speech/Hearing
4- Cognition
5- Personal/Social/Adaptive
Key Principles
** Consistency in pattern of children’s developmental progress.
- Motor development is a continuous process and occurs in an orderly fashion
- Motor development proceeds in a cephalocaudal direction
- Begins with control of neck muscles, then trunk muscles, followed by proximal and distal limbs
- After this is achieved the child can then pull to stand
** They can lift their heads with good control at 3 months, sit independently at 6 months, crawl at 9 months,
walk at 1 year and run by 18 months.
- The child learning to walk has a wide-based gait
- Walks with legs closer together, a heel-toe gait develops and the arms swing symmetrically by 18-24
months
- The sequence of development is the same in all children BUT the rate of development varies between
children
- The rate of development varies with children even among siblings
Note: The rate of attainment of milestones in one area may not parallel that in another
- Certain primitive reflexes must regress before corresponding voluntary movements can be attained
Primitive Reflexes
** Normal newborns have reflexes that facilitate survival (rooting + sucking) and sensory abilities that allow
them to recognize their mother within a few weeks of birth
** The retina is well developed at birth BUT visual acuity is poor (20/400) because of a relatively immobile
lens
- Acuity improves rapidly over the first 6 months
- Fixation and tracking becomes well developed by 2 months
Note: Extension of the extremities should result in spontaneous recoil to the flexed position
4- Grasp Reflex- palmar grasp with the placement of a finger in the neonate’s palm. Disappears by age 4
months
5- Placing & Stepping-
6- Asymmetric Tonic Neck Reflex- Forcibly turn the infant’s head to one side, the arm and leg on that
side will extend while the opposite arm and leg flex (fencing position)
Postural Reactions
- Help maintain orientation of the body in space
- These righting reactions- up to 12 months
- Protective equilibrium response at 4-6 months
- Parachute reactions- at 8-9 months-
Parachute Reaction- When an infant is held in ventral suspension and is tilted abruptly forward towards the
floor the response is a protective abduction of arms, extension of elbows and wrists and spreading of fingers
- In normal infants the response is symmetrical
- Asymmetry of the response is seen in infants with hemiparesis and an early sign of cerebral palsy
Gross Motor
Head Control 2-3 months
Roll over 4-5 months
Sit unsupported 6 months
Crawl/creep 7-8 months
Pull to stand 9-10 months
Cruise 10-11 months
Walk 12 months
Run, kick 18 months
Hop 20 months
Up and down stairs 24 months
Ride tricycle 36 months (3 years)
Note: Infants roll over from front to back initially and then from back to front later on
Fine Motor
Fix & Follow 6 weeks
Hand regard 3-4 months
Reaches 4 months
Transfers 6 months
Pincer grasp 9 months
Scribbles 14 months
Hand skills 18+ months
** Mature pincer grasp- holding objects between the thumb and forefinger
- Most young children have symmetrical movements
- Children should not have a significant hand preference (handedness) before 18 months
- If a child shows a preference for a hand before 18 months, they should be investigated because there
may be weakness on one side.
Personal Social
Language
Cooing 2 months
Turns to sound 4 + months
Babbles 6 months
Non-specific dada/mama 8 months
Specific words 12 months
Follows 1-step command 14 months
Shows parts of body 16 months
2- word sentences 24 months
Intelligible speech 36 months
Note: Child turns to sounds at 4 months BUT at 6 months there is a definitive turn to source of sound
Cognitive
Concept of object permanence 7-9 months
Concept of time 24+ months
Can perform mental operations 6-11 years
Capacity for abstract thought > 11 years
Object Permanence- is the understanding that objects continue to exist even when they cannot be seen, heard
or touched
** At 6-11 years problems related to learning disabilities etc are discovered when the child attends school
Developmental Delay
** Failure to achieve developmental milestones at the expected age
** Delay may be global or specific to one area of development
** Child health surveillance important to be able to track trend
** Plateau pattern- may have had a severe insult at a point in time that plateaus the growth
- Ex: Severe meningitis- with the resultant sequelae of impaired posture and tone
Evaluation of Development
History:
- Family history
- Perinatal issues
- Acquired infections
- Seizures
- Poor feeding or growth
- Toxin exposure
- Psychosocial issues
Investigations:
- Vision and hearing assessment
- Chromosome studies
- Metabolic studies
- Neuroimaging
Appropriate Referral
7. Nutrition - 15/01/10- PROF. THAME
Nutritional Needs of the Infant
** The infant should be ideally breastfed for the first 6 months of life
- Breast milk has ALL the nutrients needed for this time
- Breast fed babies should not be fed water
- The foremilk contains water and this satisfies the thirst of the baby
- As the baby continues sucking the rest of the milk following the foremilk becomes thicker and contains
the majority of the nutrients needed
** Physiological changes occur in the gut that allows digestion of milk initially and eventually transitions to
complex foods at 1 year
- Changes occur from mainly a sucking action to a chewing action
- Other physical changes that allow a transition from breastfeeding to solid foods are head control,
sitting up
- Developmental changes that facilitate eating solid foods include recognition of the spoon, interest in
other persons eating
Growth
** Babies normally lose weight in the first few days after birth.
- They lose weight, hit a plateau and then begin increasing their weight
- The initial weight loss after birth is because during this time 70-80% of their weight is water
- Approximately 10% of their birth weight should be lost initially
- If more than 10% is lost, investigations should be done
Note: Breast-fed babies lose more weight than bottle fed infants
- Within the first 10-14 days the infant regains its birth weight
Growth Rates
** In utero between 18 and 34 weeks the fetus increases its weight by 34g per day
- In neonatal life the infant increases its weight by 20-30g per day
** Growth rates per day in the first year of life is greatest and exceeds any other time in the life cycle
- Growth slows after 12 months and the appetite decreases as well
- Between 2-6 years of life the growth rate is slow and the appetite is poor
** Growth rates are higher in early infancy than at any other time, including the adolescent growth spurt
** Growth charts are used to monitor growth. Most children track along a centile curve
- However crossing two centile lines is a red flag
** Because of the high nutrient requirements for growth and the body composition, the young infant is
especially vulnerable to undernutrition
- Slowed physical growth is an early and prominent sign of undernutrition in the young infant
Acute delay in growth is due to illness. Chronic delay in growth is most likely due to nutritional reasons.
Energy Cost
** Infants need more than twice as much energy/kg as adults
- Infants need 93-120 Kcal/kg/day
- Adults only need 40 kcal/kg/day
** Parents should be aware of child-sized portions. Giving too much food at once will overwhelm the child
and may discourage eating
** Parents should create a routine for meals, this will encourage a child to eat
Slides #14-15
** Look at the distribution of choices among food groups. Children may be picky in spurts.
- Therefore an isolated day or 2 of unbalanced eating is alright
- As long as the overall trend over the past 2 weeks is balanced
- Expect a nutritionally adequate diet on a weekly average not daily
** A daily food plan is interpreted as the average of intake for several days up to a week
** Calories vary from day to day. A child between one and 3 years should have:
- 40 calories per inch of height OR 1000-1300 calories per day
Note: When a breastfed infant is first being offered food that is not the breast it should be initially given by a
caregiver who is not nursing the infant
- If the nursing mother attempts to offer another type of food, the infant will smell the breast milk and
refuse the food being offered
Iron
** Children 1-3 years need 15 mg iron per day. Iron deficiency anemia continues to be a problem up to 2 years
** IDA may be the result of two common nutritional errors:
1- Over consumption of milk- more than 16-24 oz per day = More that 2-3 cups per day. 1 cup = 8oz. Over consumption of milk replaces
the intake of nutrients necessary for growth and development
- Resultant low intake of iron containing foods
Note: Children who have suffered malnutrition may have deficit BUT their stimulation and environment may
counter this insult
** The adherence of carbohydrates to the tooth’s surface is the biggest dietary factor that promotes tooth
decay
- Bacteria in the mouth ferments the carbohydrate
- This leads to the production of acid which breaks down the enamel and causes dental caries
Childhood Obesity
** Worldwide 11% are overweight and 14% are at risk. Most likely cause is low physical activity as opposed to
caloric intake
** The probability of obesity persisting into adulthood has been estimated to increase from 20% at 4 years to
80% at adolescence
** Obesity is associated with cardiovascular and endocrine abnormalities (dyslipidemia, insulin resistance,
type II diabetes)
- Orthopedic problems, pulmonary complications, mental health problems
- Hypertension, artherosclerotic disease
** BMI is the standard measure of obesity in adults. Its use in children provides a consistent measure across
age groups
**Obesity is defined as a BMI at or above the 95th percentile for age and gender
** The at risk for being over weight are those above the 85th percentile but below the 95th percentile for age and
gender
Note: For children younger than 2 years, weight for length greater than the 95th percentile indicates overweight
Prevention Strategy
1- Encourage the child to eat slowly
2- Allow children to stop eating when they are full
3- Teach children to enjoy the social aspect of eating
4- Select low fat snacks
5- Serve appropriate portions for age
6- Do not tie self worth to eating or weight
7- Avoid overrestricting children’s energy intake during periods of growth
8- Encourage daily physical activity for the whole family
Treatment Strategies
** Therapy should be based on risk factors:
- Age
- Severity of obesity
- Comorbidites
- Family history and support
** For all children with uncomplicated obesity, the primary goal is to achieve healthy eating and activity
patterns
- Not necessarily to achieve ideal body weight
** For children with a secondary complication, improvement of the complication is an important goal
** For the at risk child (BMI >85th and < 95th percentile for age and gender) without complications the goal
should be maintenance of baseline weight
- Therefore portion sizes should be cut and exercise encouraged
- Maintain a stable weight or slow rates of weight gain
- This allows the child to grow into his or her height
- Therefore allows the height to catch up with the weight
Case 1
A 3-year-old presents with a 1-week history of a pruritic skin rash “all over” but primarily involving his
legs and arms. Mother says some are beginning to look “like sores”. The pruritus is worst at nights. He is
otherwise well with no constitutional symptoms.
Infectious Causes
- Varicella- absence of systemic symptoms
- Scabies- typical burrows, propensity for hands and soles. Presence of excoriated papules and pustules
and a history of severe itching at night suggest infestation with the human body louse
- Fungal infections
- Pityriasis rosea- Papulosquamous eruptions, typically the generalized eruption is preceded for up to 30
days by a solitary, larger scaling plaque with central clearing
Non-infectious Causes
- Atopic eczema- childhood eczema (flexural eczema) usually found in the antecubital and popliteal
fossae, the neck, wrists and sometimes hands or feet
- Urticaria/allergic reactions
- Contact dermatitis
- Insect bites/Papular urticaria- history of being bitted by insects. Characterized by grouped
erythematosus papules surrounded by a urticarial flare
- Distributed over the shoulders, upper arms and buttocks
- Usually no other family members are affected
- Psoriasis- erythematosus papules covered by thick white scales
On examination there is a papular rash on his forearms and legs with excoriation of some papules but no
crusting. There are many superficial scratch marks in the surrounding area.
Where else would you like to examine to aid in making a definitive diagnosis? Please give reasons.
- Examination of hands and soles for signs of burrows
- Linear burrows about the wrists, ankles, finger-webs, areolas, anterior axillary folds, genitalia
On further history his brother has had a similar rash for the past 3 days.
** Permethrin 5% is the treatment of choice for scabies. Applied as a single overnight application
- Treatment of ill contacts
- Wash clothes and bedding with hot water
Case 2
An 8-month-old female infant presents with a history of a “fine rash” on her chest and back for 2 weeks
and her skin “seems dry”.
What are the possible causes of this rash?
She had no significant history of pruritus and is otherwise well. She had a similar rash at age 3 months,
which resolved spontaneously.
On examination there are patches of fine papules involving her neck, chest and back. There is mild
desquamation involving her eyebrows and scalp.
Case scenario 1
A mother brings her 6-week-old infant for immunization; counsel her on the benefits of immunizations in
general and on the side effects of the vaccines you are about to administer.
- As a infant grows eventually he loses the protection of maternal antibodies that has been passed along
via birth and breastfeeding
- Immunization helps to continue their initial protection
- Exposing the child to weakened versions or dead cells of agents that cause illnesses with significant
morbidity and mortality in children will prevent them from getting these illnesses
- Immunization is a proven tool for controlling and eradicating
- Childhood immunization helps the immune system to build up resistance to disease
DPT
- Redness, pain and swelling at the site of injection
- Irritability and fever
OPV
- Loose stools
- Rarely can cause vaccine-associated polio
- Ensure proper hand washing before and after changing diapers because the live virus will be shed in the
stool for up to 6-8 weeks after receiving the vaccine
Case scenario 2
A mother brings her 8-month infant who is presently cruising, for a well child visit; what anticipatory guidance
would you give her about injury prevention in the home?
Crib Safety:
- Remove stuffed toys etc from the crib because they can step on it and attempt to climb out
- Remove hanging mobiles from reach
- Remove hanging curtain cords
Case scenario 3
A mother brings her 18-month-old toddler for a routine well baby visit; counsel her on toilet training.
** Toilet training involves the ability to both to inhibit a normal reflex release action and then relax the
inhibition of the involved muscles
** The child must develop certain skills in order to be successful at toilet training:
i- Motor Skills- to stand, sit, and walk unaided
ii- Verbal Skills- to express needs
iii- Social skills- to be uncomfortable when messy
iv- Sensory Skills- to retain a full bladder/rectum. Therefore the child should display evidence of dry
periods. This suggests a cognitive skill which allows them to hold in their urine
2- Allow the child to become comfortable with the potty before starting. Allow the child to play
with it and sit on it with their clothes on
3- Encourage cleanliness and dryness by changing children frequently. Parents should ask their
children whether they need to be changed using the appropriate vocabulary
4- Explain the connection between dry pants and going to the potty
5- Help children understand the physiologic signals for using the toilet.
6- Routinely place the child on the potty at set intervals. Also place the child on the potty after naps
and after meals.
** Encourage children with rewards and positive approval. Do not punish them for accidents, simply change the
clothes quickly.
Case scenario 4
A mother brings her 6-year-old male child who is still wetting his bed at night. What key information do you
need to elicit from the history and examination and how would you manage this child?
Enuresis is defined as involuntary or intentional urination in children whose age and development suggest
achievement of bladder control
- Voiding into the bed or clothing at least twice a week for at least 3 consecutive months
Causes of Enuresis
** Primary nocturnal enuresis is rarely related to an organic cause. The following are some of the causes:
1- Faulty Toilet Training-
2- Maturational Delay- the development of the inhibitory reflex of voiding may be delated in some
children
- This may contribute to enuresis until the age of 5 years
- Unlikely that maturational delay persists as a cause of enuresis beyond this age
3- Small Bladder Capacity- some children with enuresis have smaller bladder capacities
4- Sleep Disorder/Impaired Arousal- may have diminished arousal during sleep
5- Allergens- the ingestion of caffeine containing beverages may exacerbate nocturnal enuresis
6- Nocturnal polyuria/Relative vasopressin deficiency- Non-enuretic children have a diurnal variation
in vasopressin secretion
- This rhythm is disrupted in some children with enuresis, resulting in nocturnal polyuria
7- Dysfunctional Bladder Contraction- contractile disturbances of the bladder affecting normal voiding\
Note: When primary enuresis is both nocturnal and diurnal, some of the above causes of secondary enuresis
should be considered
Note: Enuresis has a familial basis. As many as 77% of children are enuretic if both parents were similarly
affected
Management
** Management is dependent on the history and diagnosis of the patient in terms of primary or secondary
enuresis.
- Need to rule out underlying organic causes
** Conditioning Therapy- involves the use of an alarm that is triggered when children void during the night
- Children are awakened by the sounding of the alarm and further urination is inhibited
- Eventually bladder distention is associated with inhibition of the urge to urinate
Note: The management of secondary enuresis should focus on the treatment of the causal disorder
Case scenario 5
A mother brings in her 2-year-old because she thinks the child is a picky eater and is small for her age. What
key information do you need to elicit from the history and examination and how would you manage this
child?
** Management depends on whether the child is well but is simply a picky eater OR if the child is
undernourished by objective standards
Strategies
- Tell parents that they should not allow the child to substitute a snack for a meal
- Different food groups- teach the parents that the child can get starch from alternate areas eg bread vs rice
- Find good foods that the child wants to eat and allow them to eat it
- Disguise foods
- MVT to supplement
- High energy drinks to support decreased caloric intake
10. Pneumonia
Pneumonia
Pneumonia- defined as infection of the lung parenchyma
** The incidence of pneumonia is highest in infancy and remains relatively high in childhood
- Incidence is low in adults and increases again in old age
- Caused by a variety of viruses and bacteria
- Note: In half of cases no causative pathogen is identified
- Viruses are the most common cause in younger children and bacteria are commoner in older children
** The pathogens that cause pneumonia vary according to the child’s age:
2. Infants + Young Children- Respiratory viruses are common especially respiratory syncytial virus
- Bacterial infections such as streptococcus pneumoniae, hemophilus influenzae, Bordatella pertussis,
Chlamydia trachomatis
- Staph aureus is an infrequent but serious cause
** In temperate climates, pneumonia is more common in cold months due to enhanced person-to-person droplet
spread of pathogens due to crowding
- Also due to decreased host resistance due to impaired mucociliary clearance from dry indoor air
Pathogenesis
** Pneumonia usually follows an upper respiratory tract infection
- Organisms that cause LRTIs usually are transmitted by droplet spread directly from close contacts or
indirectly by contaminated fomites
** The normal pulmonary host defense system consists of multiple mechanical barriers:
- Saliva
- Nasal hair
- Mucociliary apparatus
- Epiglottis
- Cough reflex
** Humoral immunity including the secretory immunoglobulin (IgA) and serum IgG defends against
pneumonia
- Phagocytic cells (neutrophils, alveolar macrophages) also play a role in defense
Etiology
Chlamydia trachomatis causes a distinctive respiratory tract illness usually at 6 weeks of age
- Due to vertical transmission
- Present with tachypnea
- Radiographs show interstitial infiltrates
- BUT children are afebrile and do not appear ill
Pneumococcal pneumonia is the most common pyogenic lung infection throughout childhood
Clinical Features
** Fever and difficulty breathing are the commonest presenting symptoms
- Usually preceded by an URTI
- Other symptoms include: cough, lethargy, poor feeding, “unwell” appearance
- Localized chest, abdominal or neck pain is a feature of pleural irritation and suggests bacterial
infection
** The overall severity of illness in children with lung findings of pneumonia should be assessed.
** Those that are ill-appearing, dehydrated or in respiratory distress require rapid and aggressive management
including:
- Blood cultures
- Chemistry profiles
- CBC
- Chest Radiography
- Administration of IV fluids, oxygen and antibiotics
Note: Outpatient management is sufficient for most children diagnosed with pneumonia in primary care
practice
Management
** Classic bacterial pneumonia, usually caused by pneumococci has:
- Abrupt onset- often following an URTI
- Fever
- Mild respiratory distress
- Cough that may be productive
- Focal findings on examination
- Chest pain + no wheezing
- Extra respiratory symptoms
** Children with viral LRTIs generally present with upper respiratory infection symptoms
- They are usually not febrile or toxic
- Wheezing is common
Note: Children with an abrupt onset of symptoms, ill appearance, high temperature or focal pulmonary findings
on examination should be treated with a beta-lactam because this indicates higher probability of bacterial
infection
Complications
** Major suppurative complications of pneumonia include:
- Parapneumonic effusion- type of pleural effusion that develop in association with bacterial pneumonia
- May be simple and sterile
- Can develop as purulent effusions with resultant empyema
- Ill appearance, febrile, tachypnea, chest pain and splinting
- Lung abscess- diagnosed based on chest imaging that shows a thick-walled cavity with an air-fluid
level in a child with symptoms of pneumonia
- Lung abscesses usually develop following an aspiration event
- May be related to a seizure or underlying neuromuscular disorder
- Mouth organism such as streptococcus, anaerobes, staph aureus, gram negative rods are usually
involved
- Tuberculosis should be considered
- Necrotizing pneumonia- rare complication of bacterial pneumonia in which liquefaction and necrosis
of lung tissue is caused by toxins of highly virulent organisms
Recurrent Pneumonia- is defined as more than one radiographically confirmed episode in a year
- OR more than 3 episodes in a lifetime
Pathology
** Lobar pneumonia has 4 stages:
1- Congestion- lasts 24 hrs and is characterized by vascular engorgement with fluid and neutrophils in the
alveoli
2- Red hepatization- involves fibrin deposition in the alveolar spaces and extravascation of red blood cells
3- Grey hepatization- is characterized by contracting fibrinous plugs containing degraded cells in the
alveolar spaces
4- Resolution- begins after 1 week and involves digestion and macrophage-mediated phagocytosis of
fibrinous material
** Interstitial Pneumonia- the walls of the alveoli and interstitial septae are involved
- The alveolar space is spared
- Interstitial cellular infiltrate is present that mainly includes lymphocytes, macrophages, plasma cells
Management Neonates
** Bacterial pneumonia in the first day of life may be impossible to distinguish from:
- Hyaline membrane disease Lack of surfactant that is needed for proper expansion of lungs & formation of hyaline material in the lung spaces
- Transient tachypnea of the newborn
** Therefore respiratory distress in newborns generally should be treated as bacterial pneumonia until
proven otherwise
- When associated with chorioamnionitis it is caused most commonly by E. coli or group B streptococci
Note: Neonates may develop bacterial pneumonia transnatally in the absence of maternal chorioamnionitis
- In these cases the causative organism is likely to be group B streptococcus
11. The Febrile Child
Normal Body Temperature = 37 deg C or 98. 6 deg F
Fever- is defined as an increase in internal body temperature by at least 1-2 deg over what is considered normal
body temperature
- Therefore a fever can be defined as an elevation of body temperature to at least 100.4 deg F
** Most febrile children have a brief, self-limiting viral infection
** Factors that need to be considered are:
- Past medical history
- Ill contacts
- If a specific illness is prevalent in the community
- Immunization status
- Recent travel abroad
- Contact with animals
- Predisposition to infection- chronic illnesses
How would you determine if this child has fever? What factors affect body temperature?
** To determine if a child has a fever begin with the history. Elicit from the parents information regarding
duration of fever, how the temperature was taken, maximum height of fever documented at home
- Associated symptoms- activity level of the child, appetite changes, rigor
- Nature of the fever
- Any chronic medical conditions
- Any medications taken
- Medication allergies
- Fluid intake
- Urine output
- Exposures and travel
- Immunization information
Rigor- is an episode of shivering or shaking followed by excessive sweating that follows a rapid increase in
body temperature
** Measure temperature, heart rate, respiratory rate, blood pressure and oxygen saturation
** Perform a complete physical exam, including a neurologic exam
- Note especially the child’s degree of toxicity and hydration status
** Changes in general appearance that may contribute to an ill or toxic appearance include:
i- Head- bulging or sunken fontanelles in young children (Eg. Increased CSF pressure or Dehydation due to Gastro)
ii- Eyes- discharge, pupil size (Eg. Allergies or Occular swelling in measles)
iii- Ears- signs of ear infection (Ear boxing, Cries when pinna is pulled ot tragus pressed = pain due to inflammation)
- Loss of light reflex, bulging, red and immobile tympanic membrane
iv- Nose- nasal discharge (Allergies, Severe rhinitis with measles)
v- Mouth- dry mucus membranes or lesions, excessive drooling
vi- Throat- erythema, exudates, lesions,
vii- Neck- signs of meningeal irritation or adenopathy
viii- Heart- murmur, rubs, tachycardia, bradycardia
ix- Lungs- abnormal lung sounds
x- Abdomen- rigidity, guarding, abnormal bowel sounds
xi- Genitals- rash, discharge, urinary changes (UTI)
xii- Neurologic status- lethargic, non-consolable
xiii- Extremities- signs of osteomyelitis, cellulitis, septic arthritis
** Factors affecting body temperature include: physiological causes and non-physiological causes
Physiological Causes
i- Endocrinopathies- hyperthyroidism
ii- Diurnal variations- lower temperatures in the early morning and higher temperatures in the
evening/late afternoon
iii- Ovulation
iv- Factors which increase the metabolic rate
v- Exposure to excessive environmental heat
vi- Exercise
Non-Physiological Causes
i- Clothing- increased amounts of clothing can raise temperature
ii- Drugs- steroids, cocaine, anesthetics (malignant hyperthermia in susceptible individuals), atropine,
overdose of salicylates
iii- Infections- viral, bacterial, parasitic etc
iv- Ectodermal dysplasia- congenital absence of sweat glands
v- Malignancies
vi- Metabolic diseases
vii- Autoimmune diseases- SLE, Kawasaki disease
viii- Chronic inflammatory conditions
ix- CNS abnormalities
** Proteins, breakdown products of proteins and lipopolysaccharide toxins released from bacterial cell
membranes along with other exogenous Pyrogens stimulate the body’s immune system
- As a result macrophages and white blood cells are activated
- They produce cytokines such as IL-1, IL-6, TNF
- These cytokines stimulate the production of Endogenous Pyrogens
- The result is that prostaglandins (PG-E2) are produced that reset the hypothalamus
- This re-setting activates physiological and behavioral changes to release heat from the body
What other causes of elevated body temperature exists and how do they differ from true fever?
** Other causes of elevated body temperature include dehydration
- Over-bundled with clothes in a relatively warm environment
** True fever is defined as an increase in body temperature due to an elevation of the thermal set point in
the anterior hypothalamus secondary to the release of Pyrogens
** With hyperthermic conditions other than true fever, the hypothalamic set point is not adjusted
Difference between fever and hyperthermia 1
- Therefore a fever occurs when the body sets the core temperature to a higher temperature, through the
action of the anterior hypothalamus
- However hyperthermia occurs when the body temperature is raised without the consent of heat control
centers
** Non-febrile hyperthermia occurs when heat gain exceeds heat loss such as with:
- Inadequate heat dissipation
- Exercise
- Drugs- amphetamines, cocaine, SSRIs
- Environmental Causes
- Conditions that result in increased metabolic activity
Note: In addition giving anti-pyretics can reduce true fever. These drugs have no benefit in the treatment of
hyperthermia Difference between fever and hyperthermia 2
** Hot, dry skin is a typical sign of hyperthermia. Fever by contrast usually produces cool, damp skin
. Difference between fever and hyperthermia 3
p) How do you classify fever?
Fever classification
Temperature in rectum,
Temperature in mouth Temperature under the arm
vagina, or ear
(oral temp.) (axillary temp.)
(core temp.)
Grade °C °F °C °F °C °F
low grade 38-39 100.0-102.2 37.2-38.2 99-100.8 36.8-37.8 98.4-100.2
moderate 39-40 102.2-104.0 38.2-39.2 100.8-102.6 37.8-38.8 100.2-102
high-grade 40-41.1 104.0-106.0 39.2-40.3 102.6-104.6 38.8-39.9 102-104
hyperpyrexia >41.1 >106.0 >40.3 >104.6 >39.9 >104
** Fever can also be classified according to whether it is continuous or intermittent Fever classification 2
iv- Continuous Fever - Temperature remains above normal throughout the day and does not
fluctuate more than 1 deg C in 24 hrs
- Ex: typhoid fever
v- Intermittent Fever - Elevated temperature is present only for some hours of the day and
becomes normal for remaining hours
- Ex: malaria
vi- Remittent Fever - Temperature remains above normal throughout the day and fluctuates more
than 1 deg C in 24 hrs
- EX: infective endocarditis
vii- Hectic Fever - persistent elevations of temperature but with wide variations throughout the day
- Also known as a spiking fever
- Ex: abscesses, Pel-Ebstein fever (cyclical fever associated with Hodgkin’s lymphoma)
Defn: Fever of Unknown Origin- Fever that lasts > 7 days which has been adequately
investigated and no cause can be found
Otitis Media
- Signs of ear boxing
- Irritability
Pharyngitis
- Drooling
- Refusing food
Features of sepsis
Diarrheal Disease
- Viral diarrhea tends to be watery and non-bloody
- Blood + mucus in the stool along with high fever is suggestive of dystentery (bacterial infection)
Kawasaki Disease
- Enters the differential for a fever that lasts longer than five days
- Initially known as mucocutaneous lymph node syndrome
- 80% of patients are younger than 5 years
** The diagnostic criteria are fever for more than 5 days and at least 4 of the following features:
1- Bilateral, painless, non-exudative conjunctivitis
2- Lip or oral cavity changes- lip cracking/fissuring, redness, strawberry tongue (red tongue + prominent
papillae),, inflammation of the oral mucosa
5- Extremity changes- redness of palmar surfaces, swelling of the dorsum of hands/feet, desquamation of
skin over these areas
** The potential for cardiovascular complications is the most serious aspect of Kawasaki disease.
Complications during the acute illness include:
- Myocarditis
- Pericarditis
- Valvular heart disease (mitral or aortic regurgitation)
- Coronary arteritis
** Coronary artery lesions range from mild transient dilation to large aneurysms
- Aneurysms rarely form before day 10 of illness
- Untreated patients have a 15-25% risk of developing coronary aneurysms
** Early treatment using IVIG is required before the 10th day of the illness
- Therapy is effective in decreasing the incidence of coronary artery dilation and aneurysm formation
Note: The differential diagnosis of a fever lasting more than 5 days includes:
- Unusual viruses- eg EBV
- Bacterial focus of infection
- Inflammatory diseases
- Malignancy
- Kawasaki Disease
What other historical data would you elicit if the boy was less than one month old and older than 3
years?
** In addition the mother should be asked if she had symptoms of high fever, skin rash, or joint pain at any time
during pregnancy
- UTI during pregnancy
- Vaginal discharges during pregnancy
- If she received HIV treatment or prophylaxis before delivery
** Information regarding the nature of the delivery:
- Mode of delivery
- Prolonged rupture of membranes
- Rupture of membranes before the onset of labor
- Septic or traumatic delivery
Chorioamnionitis- is an inflammation of the fetal membranes (amnion + chorion) due to bacterial infection
- Results from bacteria ascending into the uterus from the vagina
- Most often associated with prolonged labor
- Uterine tenderness
- Foul odor
- Fetal distress
** Information about the neonates nursery course should be noted, including the age at which the patient was
discharged from the nursery
- If circumcision was done or not
- Use of peripartum or antepartum antibiotics
- Diet and if formula fed, hygiene surrounding bottle preparation
- Sleep histories
Note: Decreased oral intake or an acute change in sleep patterns may be clues to infection
What features in the examination would you elicit to rule out meningitis? How do the features change
with age?
Meningism is the triad of:
- Nuchal rigidity
- Photophobia
- Headache
** Signs of meningeal irritation. Inflammation or irritation of the meninges can lead to increased resistance to
passive flexion of the neck and the extended leg
- The corresponding signs are neck stiffness (nuchal rigidity) and Kernig’s sign
Kernig’s sign is positive when attempts to extend the knee are resisted by spasm, which is detected in the
hamstrings, and the other leg may flex at the hip and knee
Note: Kernig’s sign is not present in local causes of neck stiffness
- EX: cervical spine disease or raised intracranial pressure
** After age 3 months the child may display symptoms associated with bacterial meningitis:
- Fever, vomiting, irritability lethargy or any change in behavior
Note: Fontanelle bulging, diastasis of the sutures and nuchal rigidity point in meningitis in young infants but are
usually late findings
** After age 2-3 years children may complain of headache, stiff neck and photophobia
What are the common causes of fever in children less than one month old, 3-36 months, older than 3
years?
< 1 month
- Serious bacterial infections
- Vertical transmission of infection
>3 years
- Viral infection
What groups of children are considered high risk when they have a fever?
- Neonates up to 2 months- some persons extend the definition to include children 3 months and younger
- Children with incomplete immunizations or immunizations not up to date for age
- Immunocompromised children
- Children with indwelling catheters, lines or shunts
- History of chronic illness- sickle cell, cancer, diabetes
- Children with a stoma- meningomyelocele
- Steroid therapy or chemotherapy
- Malnourished children
Note: Children with congenital heart disease are not necessarily higher risk or more prone to infection in
general BUT they are susceptible to developing specific conditions such as infective endocarditis
** A chest radiograph should be considered for neonates with signs of respiratory illness
- Coryza, cough, tachypnea, rales, rhonchi, nasal flaring or wheezing
** A child under 18 months that is moderately ill, one should have a high index of suspicion
- Therefore an LP is often performed even in the absence of meningeal signs
** The approach to fever in a febrile infant depends on the clinical findings after examination
i- NSAIDs - have a longer duration of action but should not be used until gastritis is ruled out,
especially if a child is not eating (NSAIDS can cause inflammation of the gastric mucosa)
ii- Acetaminophen - side effects are liver toxicity after overdose
** No evidence that tepid sponging works. Sponge the child from head to toe with room temperature water
- But do not allow the child to shiver
** Do not bundle children with fever and do not immerse in ice water
12. Skin Rashes
** Rashes are assessed in terms of appearance:
i- Macular- flat
ii- Papular- raised
iii- Squamous- scaly
iv- Vesicular- fluid filled
v- Bullous- large and fluid filled
** The extent of the rash is also determined. Rashes may be described as generalized or localized
- Note the location of the rash as well
** In addition, rashes that are associated with fever can be differentiated from those that are not.
- Rashes seen in febrile children are called exanthems
- Exanthems may be associated with enanthems (lesions in the oral cavity)
** Atopic dermatitis affects about 3-5% of children. Males and females are affected with equal frequency
- The itching associated with atopic dermatitis and other pruritic rashes is worse at night
- Symptoms are often worse during the winter months
Pathophysiology- Scabies
- Inflammatory response is triggered by an infestation with a mite Sarcoptes scabiei
- Adult female burrows under the skin and lays her eggs
- After 2 weeks the eggs become adults
- With time, usually 10-30 days after infestation, signs and symptoms become apparent
** The reaction relates to the development of cellular or humoral immunity to the mite, feces or eggs
- In infants the rashes may develop in areas away from the site of infestation as a sign of an allergic
reaction to foreign material
** Scabies may resemble atopic or seborrheic dermatitis in infants and young children
- The lesions may be papules, pustules or vesicles
Treated TOPICALLY = PERMETHRIN
Treated ORALLY = IVERMECTIN
- The characteristic burrow is usually about 1 cm long
- Lesions are most often noted on the skin of the hands and feet DO NOT USE HYDROCORTISONE
- Including the palms and soles in infants and young children
- Intertriginous areas- intraglueal region, groin and finger webs are commonly infected
- Scratching and secondary infection may alter the appearance of the rash
Differential Diagnosis
** The major conditions that are associated with papulosquamous eruptions in children are:
- Atopic dermatitis
- Seborrheic dermatitis
- Allergic contact dermatitis
- Scabies
- Xerosis
- Lichen planus
- Psoriasis
- Papular urticaria
- Flea bites
- Fungal infections of the skin
- Infantile acropustulosis dermatosis
Note: Symptoms of other allergic conditions, such as rhinorrhea, wheezing, food-related allergies may occur
- A positive family history is usually elicited
Contact Dermatitis
- Occur when individuals come into physical contact with an irritant or a specific allergen
- Diaper dermatitis and Rhus dermatitis (poison ivy/oak) are two common types of contact dermatitis
- Hands and exposed areas are frequently affected
- The rash is papulosquamous, oozing and may become lichenified
ii- Allergic eczematous- has a delayed onset of 18 hrs, peaks at 48-72 hrs
- May last as long as 2-3 weeks even if exposure to the allergen is discontinued
- Has features of delayed type (T-lymphocyte mediated) hypersensitivity
Xerosis (Xeroderma)
- Dry skin
- Frequently fund in patients prone to atopic dermatitis
- May be seen in other individuals under drying conditions
- EX: low humidity, frequent bathing with drying soaps
- Skin may be scaly and pruritic
- Scratching may result in excoriations
- Note: A papular eruption is usually absent
Lichen Planus
- Papulosquamous eruption
- Polygonal, brownish-pink, scaly lesions are located on the flexor surfaces
Psoriasis
- Papulosquamous eruption with more plaque-like features
- Older children- face and scalp affected
- Infants- eruptions usually occur in the diaper area
- May becomes secondarily infected by Candida
- Only mildly itchy
Papular Urticaria
- Found in children between the ages of 3 years and 10 years
- Characterized by grouped erythematosus papules surrounded by a urticarial flare
- Papules are distributed over the shoulders, upper arms and buttocks
- Lesions represent delayed hypersensitivity reactions to stinging/biting insects
- Usually a reaction to flea bites
- Other insects: mosquitoes, lice, scabies, bird + grass mites
- Usually no other family members are affected
- Treatment: Remove the offending insect
- Use topical corticosteroids and oral antihistamines to treat
Infantile acropustulosis
- Very pruritic papules and vesicles on the sides of the hands and feet
- Lesions become scaly and hyperpigmented
- Evidence of secondary infection
- Found mainly in African-American and Native American children under age 3 years
Rash History
- How long has the child had the rash?
- What did the rash first look like when it appeared
- Are other family members affected
- Have any medications been used to treat the rash
- +/- pruritis
- Associated symptoms- wheezing, rhinorrhea
- Does the child have a history of contact between the affected skin and any irritating substance
- Has the child been febrile
Examination
- Nature of the eruption and distribution
- Examine entire body
- Especially intragluteal region + web spaces between fingers and toes
Management
** Topical steroids used to treat various PS eruptions and minimize inflammation
- Triamcinolone 0.1%, hydrocortisone cream- used for atopic and seborrheic dermatitis
- Systemic steroids- may be needed for more severe exacerbations
- Psoriasis- does not usually respond to hydrocortisone 1% alone nad may require a combination tar-
hydrocortisone preparation
** The pathophysiology of the rash is variable. In some case the rash is the reaction of the body to infection or
the presence of a toxin
- Exposure to an infectious agent through droplet contamination or fecal-oral contamination
- The agent replicates usually in the reticuloendothelial system
- Lymphadenopathy is common
Viral Exanthems
Exanthem- is a widespread rash that is usually accompanied by systemic symptoms (fever, malaise, headache)
- Usually caused by an infectious agent (eg virus)
- Represents either a reaction to a toxin produced by the organism, damage to the skin by the organism, or
an immune response
** Childhood exanthems are common and are usually associated with the following viral skin infections
** Presents with fever and rash. The rash begins as raised, fiery red maculopapular lesions on the cheeks
- The lesions coalesce to give the slapped cheek appearance FIVE FINGERS ON YOUR FACE
- Lesions are warm, non-tender and sometimes pruritic
- Found scattered on the forehead, chin, postauricular areas
- BUT not on the circum-oral regions
- Within 1-2 days similar lesions appear on the proximal extensor surfaces of the extremities
- Spread distally in a symmetrical fashion
- Palms and soles are usually spared
- Trunk, neck and buttocks are commonly involved
Note: Although most children are only mildly ill, children with underlying hematologic disorders may
experience aplastic crises
Forschhermier spots- are pinpoint, rose-colored, petechial spots on the soft palate see in MEASLES, RUBELLA & SCARLETT FEVER.
Measles aka Rubeola
- High fever and lethargy
- Rash is preceded by symptoms such as sneezing, eyelid edema, tearing, copious coryza, photophobia
and eventually harsh cough = prodromic viral enanthem of measles manifesting 2-3 days before the measles rash itself. White
- Koplik spots appear on the buccal mucosain colour
- Discrete maculopapular rash begins when the respiratory symptoms are maximal
- Rash spreads quickly over the face and trunk and coalesces to a bright red
- As it involves the extremities it fades from the face
- Disappears completely within 6 days
- The fever peaks when the rash appears and usually falls 2-3 days afterwards
Note: The conjunctivitis associated with measles is purulent, which distinguishes it from Kawasaki
syndrome
- Measles rash usually begins on the head, especially behind the ears and around the edges of the scalp
- Spreads over the rest of the body
- Initially the lesions are discrete papules that coalesce and become pruritic
- Associated with lymphadenopathy, especially in the posterior cervical region MEASLES = postCERVICAL = Master of Ceremony
** Rash begins on the trunk and spreads to the face, neck and extremities
- Rose pink macules or maculopapules 2-3 mm in diameter
- Non-pruritic, tend to coalesce and disappear in 1-2 days without pigmentation or desquamation
** Infants may appear sickest during the prodromal phase, when the fever is very high
- Therefore may need tests to rule out sepsis
Note: In children who receive antibiotics or other medication at the beginning of the fever, the rash may be
attributed incorrectly to drug allergy
Enteroviruses
- Most common cause of exanthems in the summer months
- 68 types of enteroviruses are recognized
- Previously they were classified as coxsackievirus, echovirus or poliovirus
Scarlet Fever
- Bacterially transmitted illness that can produce a maculopapular eruption
- The rash and illness are due to an exotoxin produced by group A beta-hemolytic streptococcus
- Usually seen in young children with pharyngitis
- Incubation period is 2-5 days
- Symptoms of fever (103 deg F), headache, vomiting, malaise and sore throat appear suddenly
- Tonsils are covered with a white exudate and palatal petechiae are seen
- Edema of the papillae make them appear prominent
- The face is flushed EXCEPT around the mouth (circumoral pallor)
- A discrete facial rash is absent
- The fine rash is concentrated on the trunk and intensified in the flexor folds
- Pastia’s Lines- bright red lines noted in the antecubital fossa
- As the scarlet fever rash resolves, desquamation begins in 4-5 days
EBV
- Associated with rash in young children
- Eruption is morbilliform (measles-like)
- Lesions may be erythematosus or copper-colored
Physical Examination
** The focus of the physical examination is to help define the characteristics of the eruption
- Location, extent + degree of coalescence
Laboratory Tests
** Serologic testing is most valuable for defining a community outbreak of a specific disease
- Ex: measles
** Viral cultures are usually not obtained unless aseptic meningitis is diagnosed
** Neutropenia and lymphocytosis characterize many viral illnesses. Therefore they are not helpful in
differentiating between causal agents
- Lymphocytosis- with characteristically atypical lymphocytes distinguishes EBV infection
** Vesicles and bullae arise from a cleavage at various levels of the skin either within:
i- Intraepidermal- within the epidermis
ii- Subepidermal- at the epidermal-dermal junction
** Specific changes occur in the epidermis depending on the etiology of the vesicular exanthem:
1- Ballooning Degeneration- varicella, herpes simplex, herpes zoster
2- Spongiosis- intracellular edema as seen in dyshidrotic eczema
Differential Diagnosis
** Parasites such as Sarcoptes scabiei can cause an intensely pruritic vesicular eruption in combination with
papules and linear burrows
** Fungal pathogens that cause vesicopustular lesions that appear on the feet include:
- Trichophyton rubrum
- Epidermophyton floccosum
** A delayed hypersensitivity reaction secondary to contact with poison ivy/oak causes the classic linear
vesicular lesions of Rhus dermatitis
** The differential diagnosis of acute vesicular exanthems also can be organized according to the distribution of
the lesions.
- Distinctive locations as well as specific patterns are important
- Presence or absence of fever (temperature >101 deg F)
- Historic information- such as known exposure to varicella prior to eruption, contact with poison ivy/oak
- Presence of a specific prodrome
- Pain on swallowing often occurs with coxsackie virus infection
Note: A past history of similar lesions lessens the likelihood of acute primary infection
- Suggests a chronic condition such as dyshidrotic eczema
Physical Examination
** Take vital signs to verify +/- fever
** Examine the oropharynx for vesicular/ulcerative lesions on the tongue, gingival, buccal mucosa, anterior
tonsillar pillars + posterior pharynx
** Examine the lips for evidence of vesicular lesions that may occur with a primary or recurrent herpes
simplex infection
** Determine if the vesicles are grouped in a particular dermatomal distribution as with zoster (shingles)
- More generally distributed and in various stages of development as in varicella
- Linear distribution may suggest contact with poison ivy or poison oak
Laboratory Tests
** Definitive confirmation of scabies can be made by microscopic examination of skin scrapings from
suspicious lesions
- Presence of the adult mite or ova, larva or feces is diagnostic
** A Tzanck smear shows intranuclear viral inclusions may be useful in making a preliminary diagnosis of
a herpesvirus
Treatment
** Conditions are usually self-limited and require only supportive therapy
Note: The primary preventive medicine has changed the causes of death of children over the last century
Therapeutic Alliance- requires an understanding and appreciation of the individual context of each child and
his/her family
- Allows greater opportunity for primary prevention and early detection of disease between health
supervision visits
Newborn
- Prematurity
- Jaundice
- Respiratory distress
- Congenital anomalies
- Infection
Infant
- Diarrheal illnesses
- Respiratory infections
- Nutritional problems
- Injuries
Child
- Poisoning
- Accidents + injuries
- Infections
- Nutritional problems
Adolescent
- Accidents + injuries
- STI/HIV
- Teenage pregnancy
- Depression/suicide
- Substance abuse
Key Successes
i- Immunization- protects children against several severe life threatening diseases
- Has eradicated certain diseases
- Has made other diseases extremely rare
ii- Breastfeeding initiative
iii- Use of oral rehydration solutions- prevent dehydration
iv- Fluoridation- decrease in tooth decay
v- Seatbelt legislation
vi- Antiretroviral prophylaxis
** The MOH in Jamaica recommends a minimum of 10 well child visits over the first two years of life
- At well child visits malnutrition or obesity is detected at an early stage
- Allows action to be taken early
** The 5 effective areas of primary prevention are:
- Nutrition
- Immunization
- Dental care- first visit to the dentist for examination by 12-18 months of age
- Accident prevention
- Prevention of emotional and developmental problems
Dental Care
- Before eruption of teeth clean oral cavity with soft washcloth and water
- No toothpaste under the age of two
- Supervise brushing of teeth up to age 8-10 years
Accidents/Prevention
** Accidents are the second leading cause of death in the 1-4 year age group
- Leading cause of death in the 5-9 year age group
- Among adolescents 10-19 years it was the second leading cause of discharges from public hospitals and
the leading cause of death in government hospitals
** The focus of accident prevention varies with age and developmental stage
1- Transport- occupants/pedestrians
2- Home- falls/lacerations, blunt injuries, burns, drowning, poisonings
Sleeping Problems
- Night awakening
- Persistently sleeping in parents’ bed
- Nightmares
- Bed Wetting Treatment- educate parents, incentive charting, no punitive measures, restricting fluids
prior to bedtime, voiding exercises
Feeding Problems
- Picky eater
- Refusing solids
- Refusing to sit at the table for meals
- Obesity
Toilet Training
- 18 months before neurological maturity
- Motor skills- to stand, sit and walk unaided
- Verbal skills- to express needs
- Social skills- to be uncomfortable when messy
- Sensory skills- to retain a full bladder/rectum
Discipline
- Never use discipline in a child less than a year
- Appropriate discipline measures
- Define acceptable behavior
- Be consistent
- Foster open communication within the family
- Physical punishment teaches aggression
- The more often it is used the less effective it becomes
- Time outs and curtailing of privileges
Temper Tantrums
** Normally they are demands for attention or signs of frustration, anger or protest
- In between tantrums the child’s disposition and mood are normal
** Problematic- when there are more than 5 per day or they worsen beyond 5 years old
- If there is destruction of property
- The child harms himself or others
- There is a persistent negative mood or behavior between tantrums
Sexual behavior
- Children are naturally curious about their body
- Teach proper names for body parts
- Masturbation is normal
14. Meningitis
** Meningitis occurs when there is inflammation of the meninges covering the brain
- Confirmed by finding inflammatory cells in the CSF
- Viral infections are the most common cause of meningitis and most are self-resolving
- Other causes of meningitis include: malignancy, autoimmune diseases, bacteria, fungi
Neonatal Disease
** Group B Streptococcus is the most common neonatal meningitis pathogen
- Sporadic cases related to Listeria monocytogenes and gram-negative agents (E. coli) continue to be
important
- The maternal genital tract is usually the source of the pathogen for both early and late onset disease
- Late onset disease is often associated with CNS infection
Note: The few cases of GBS disease occurring after 3 months of age are generally seen in infants who were
born preterm
** The majority of time transmission occurs when an infant is delivered vaginally through an infected birth
canal
Note: Ascending infection can occur despite intact amniotic membranes
- Occasionally horizontal transmission from a caregiver/health care worker occurs from a non-genital
source
- Usually related to virus transfer from mouth or hands
** Most children are not severely ill and often present with a non-specific febrile illness
- Meningeal signs may be present
** The fecal-oral route transmits enteroviruses. Cases of meningitis are most commonly in children younger
than 1 year of age
** In young neonates who have symptoms and signs consistent with sepsis, a history to elicit maternal
symptoms should be done
- Maternal enteroviral infection may precede neonatal infection in up to 70% of neonates diagnosed as
having enteroviral disease within the first 10 days after birth
Mycobacterium Tuberculosis
** Pediatric meningitis caused by M. tuberculosis tends to be a complication of primary infection in the child 5
years or younger
- Primary infection occurs after droplet inhalation
- Followed by dissemination from the lung to the lymphatics and to the bloodstream
Note: Signs/symptoms of increased intracranial pressure and meningeal inflammation such as vomiting,
apnea and seizures can also occur
** Infants older than 1 month of age and young children can also present with the same non-specific
constitutional symptoms
- Fever, lethargy, irritability
** Signs and symptoms due to meningeal inflammation and increased ICP including mental status changes,
vomiting and seizures, continue to predominate
History
** 20-25% of children with pneumococcal meningitis have a predisposing risk factor
1- Mechanical Risk Factors- CNS trauma, cochlear implants, CSF leak
2- Medical Risk Factors- HIV infection, asplenia, chronic renal disease
- Recent infections such as otitis media, sinusitis, mastoiditis can predispose a child to bacterial
meningitis
** For infants, a birth history, maternal GBS colonization status and treatment and maternal history of STI
should be elicited
- Enquire about immunization
Examination
** Meningismus is suggestive of meningeal irritation. However this is usually not present in the young infant
Note: In young infants paradoxical irritability is the usual sign of meningeal irritation
- The infant with meningitis does not want to be handled and prefers to remain motionless
** In the older child, signs of meningeal irritation should be elicited age at which these signs are reliable is 2 years of age
1- Kernig Sign- patient lies supine and the thigh is flexed at right angle to the trunk. If knee extension
from this position elicits pain, the Kernig sign is positive Don't like moving from an L to K with knee
2- Brudzinski Sign- patient lies supine and flexes the neck Brud at the head of the bed
- Positive sign occurs if the patient also reflexively flexes the lower extremities (knees)
Note: CSF culture is the gold standard for diagnosing bacterial meningitis
** Viral meningitis is characterized by a lower cell count (WBC 0.05-0.5 x10 9)
- Glucose and protein concentrations are frequently normal
- Protein value can be slightly elevated
- Gram stain is universally negative
Prognosis
- 5-10% of children with bacterial meningitis die
- Among the survivors, the risk of neurologic sequelae is highest in children who have pneumococcal
meningitis
** Anaerobic meningitis in children generally occurs as a complication of chronic otitis media with
mastoiditis, chronic sinusitis, recent craniotomy, and abdominal trauma
15. Cough, Cold, SOB
** A cough is a protective reflex to ensure airway patency
- Cough is one of the most common presenting symptoms in pediatrics
- Common in all age groups
- Involves the respiratory, cardiovascular and GI systems
Historical Information
Cough
- Type- barking, whooping, productive, non-productive
- Frequency
- Timing- diurnal variation
- Effects on patient, parents, other- does it affect sleep, causes vomiting, pain, hemoptysis
- Duration- persistent, chronic, recurrent
Cold
- Define what the patient means by “cold”- mucus, noise when the child breathes
- Color, odor, +/- blood
SOB
- Description
- Duration
Note: Receptors are not found in the lung parenchyma or the alveoli
- Therefore pneumonia may no produce a cough
- Receptors can be found both inside and outside of the respiratory tract
** Stimulation of any of these receptors by a chemical, mechanical, thermal or inflammatory irritant can
initiate the cough reflex
** The receptors send the cough message along the vagal and laryngeal nerves to the upper brainstem
- In the brain the cough center in the medulla receives the message and coordinates the cough mechanism
Sub-acute/Chronic- defined as a cough that lasts for more than 2-4 weeks
- Infections
- Non infectious- allergic rhinitis/sinusitis/asthma
Respiratory Infections
** Respiratory infections can be classified anatomically:
- Upper respiratory infections
- Lower respiratory infections
Etiology
- Viral
- Bacterial
- Mycobacterial
- Mycoplasma and Chlamydia
- Fungal
Bacterial:
- Otitis media
- Tonsillitis
- Sinusitis
- Epiglottitis
- Bacterial tracheitis
Bacterial:
- Pneumonia
- Lung abscess
- Empyema
Chronic Respiratory
LRTIMIi
T'T on,
1.11rad 1BA5ERiAI lViRAI
fBA4aI
€Ommon [ media
[
↳
Bronchi otitis
Bronchopneumonia
'
>
↳
Pneumonia
lung
↳
cold otitis abscess
↳ tonsillitis
↳
Epiglottis
↳ bronchitis ↳ bacterial tracheitis
Laryngotracheo
( viral croup)
t.CHRONI-u.LI HDD
£77 ↳ Viral : HIV related
lymphocytic pneumonia
VIRAL Non -
infectious
↳ chronic ↳ Bacterial
BACTERIAL suppurative : Tuberculosis
otitis media
infectious
•
bronchiectasis
a
cystic fibrosis
•
ciliary disorders
3- Non-infectious- chronic suppurative otitis media, chronic sinusitis
** The age of the child can influence the diagnostic possibilities. Congenital anomalies are most likely to
present in the first few months of life include:
IT
i- Tracheoesophageal fistula
ii- Laryngeal cleft- condition that results from the failure of posterior cricoid fusion
- May have stridor
- Have severe aspiration resulting in recurrent/chronic pneumonia and failure to thrive
vi- Congenital mediastinal tumors- can cause coughing if the tumor presses on the bronchial
tree
7
also present
q¥÷÷÷÷÷t÷
will
cough .
This
↳
may sensitivity
it
of cough reflex
-
cytotoxic drugs
-
thoracic radiation
viral threshold
-
8 wks
of 4-
children 715
yrs t adults
(
w/ normal history physical examination { chest radiograph
,
think drip
postnasal
:
asthma
GERD
ACE inhibitors
smoking
There is
usually more than one
etiology
" "
chronic productive wet
cough
↳ suppurative &
suggests process may require
further investigation to exclude
°
bronchiectasis
fibrosis
°
cystic
active infection
•
a
immune deficiency
** The duration of the cough can also help to determine its possible cause. Most acute coughs are infectious in
nature
- Upper respiratory tract infections initiate an acute cough through stimulation of the cough receptors in
the nose and posterior pharynx
- If nasal congestion and cough persist, a diagnosis of allergic rhinitis or sinusitis should be considered
- Serous otitis media can cause a persistent cough
- Children with pneumonia may present with either an acute or chronic cough
** The presence of a night time cough is also significant. Pathologic coughs caused by the following are morel
likely to occur at night :
- Sinusitis with post-nasal drip
- Gastroesophageal reflux
- Asthma
** The character of the cough is also important. Some conditions produce a very specific type of cough
i- Barking Cough- consistent with laryngeal edema and croup
ii- Inspiratory Whoop- is characteristic of pertussis or parapertussis
iii- Honking Cough- psychogenic coughing
Note: Bordatella pertussis, mycoplasma and Chlamydia also cause a chronic cough
** The most common cause of chronic cough is reactive airway disease (asthma)
COUGH
Children w/
t
RcI
fibrosis
think -7
cystic dysplasia
bronchopulmonary
HIV & other immunodeficiency syndromes
congenital pulmonary malformations .
Common Cold
that sore
this shows a
→
be viral
throat can
Young Infants
Laryngomalacia
** Laryngomalacia is a benign congenital disorder in which cartilaginous support for the supraglottic
structures is underdeveloped
- It is the most common cause of persistent stridor in infants
- Usually seen in the first 6 weeks of life
** The condition usually improves with age and resolves by age 2 years
Common Cold
** Combinations of runny nose, nasal congestion, sore throat, tearing, cough, and sneezing characterize the
common cold syndrome.
- Low grade fever may be present
** Changes in respiratory epithelium, local obstruction and altered local immunity are sometimes the
precursors of more severe illnesses such as: otitis media, pneumonia and sinusitis
** During and following a cold the bacterial flora change and bacteria are found in normally sterile areas of
the upper airway
- Halithosis because #
mouth often open
is
mouth
-
Symptoms
** The patient usually experiences a sudden onset of clear or mucoid rhinorrhea, nasal congestion, sneezing
and sore throat
- Cough and fever may develop and tend to be mild
- Runny eyes +/- mucus
- Not short of breath BUT parents may describe mouth breathing or noisy breathing as SOB
Note: Common cold symptoms are non-specific and they tend to occur in other illnesses
** The nose, throat and tympanic membranes may appear red and inflamed
- Nasal secretions tend to become thicker and more purulent after day 2 of infection due to shedding of
epithelial cells and influx of neutrophils
- The discoloration should not be assumed to be a sign of bacterial rhinosinusitis unless it persists
beyond 10-14 days
fever / constitutional symptoms
have
Allergic Disease will not
** Allergic disease can manifest in many ways: has asthma
- Asthma also look for eczema if
patent
- Atopic dermatitis
- Allergic rhinitis
- Allergic conjunctivitis
- Urticaria- is the clinical rash produced by vasodilation and edema of the skin as a result of an allergic
condition.
- Angioedema- is the extension of the urticarial process deeper into the dermis of the skin
- Producing circumscribed swelling
- Anaphylaxis
- Food allergies- vomiting and diarrhea
** Children with allergic disease frequently present with persistent, clear rhinorrhea, sneezing, postnasal drip
or injected pruritic conjunctiva
** Skin manifestations include dry, scaling, erythematosus rashes, wheals or subcutaneous swelling
- A recurrent cough or wheezing on chest examination is further evidence of allergic disease
Allergic Rhinitis
** Allergic rhinitis is caused mainly by an antigen-antibody reaction involving IgE
- Antigen specific IgE is produced by the B-lymphocytes of allergic patients on exposure to a particular
antigen
** The IgE attaches to mast cells in the conjunctiva and mucus membranes of the respiratory tract
- On re-exposure the antigen reacts with this specific IgE on the mast cells, releasing vasoactive
mediators
- EX: histamine, leukotrienes, kinins, prostaglandins
- These mediators produce vasodilation and edema
- Stimulates neural reflexes to produce mucus hypersecretion and sneezing
** Allergic rhinitis may contribute to the development of rhinosinusitis and asthma exacerbations
- The duration and pattern of symptoms are seasonal and related to triggers/allergens
** Symptoms include:
- Nasal congestion
- Frequent sneezing lines t panda eyes
dennie Morgan
- Rubbing of the nose →
- Clear rhinorrhea
- History of mouth breathing + snoring at nights
** On physical examination of the nasal turbinates are swollen and may red or pink
- Allergic salute- a transverse crease across the nose due to repeated rubbing of the nose ✓
- Allergic shiners (Panda eyes)- dark circles under the eyes due to venous stasis ✓
- Dennie-Morgan lines ✓
- Adenoidal facies- the mouth gains a high arched palate from chronic mouth breathing
brown colour
- Discolored conjunctive, eyelids + lips yes
- becomes in
Rhinosinusitis
** The term rhinosinusitis has replaced sinusitis because it acknowledges that the nasal and sinus mucosa are
involved in similar and concurrent inflammatory processes
co
-
14 days
- Sub acute- 4-8 weeks lasts longer
- Chronic- lasted longer than 8 weeks
** Not all of the paranasal sinuses exist from birth. The degree of pneumatization of different sinuses vary
from one individual to another
- The maxillary sinus pneumatizes first beginning between birth and 12 months of age
- The ethmoid sinuses are rudimentary at birth and do not reach adult size until 24 months of age
- Frontal + sphenoid sinuses develop after the ethmoids and do not complete opening until late
adolescence
hmmmm
Acute Bacterial Rhinosinusitis
** Acute bacterial rhinosinusitis is a bacterial infection of the paranasal sinuses that lasts less than 30 days
LT
SH 'm →
ii- Hemophilus influenzae SHiM causes ABR
iii- Moraxella catarrhalis
Note: Chronic sinusitis may be the result of the above pathogens as well as organisms such as Pseudomonas
aeruginosa and other anaerobes
- Fungi- may also be a factor in chronic infection
** Acute rhinosinusitis usually presents as a cold that lasts longer than usual
- Usually a cold that does not improve by 10-14 days or worsens after 5-7 days
- The maxillary and ethmoid sinuses are most commonly involved
Note: Chronic rhinosinusitis is diagnosed when the child has NOT cleared the infection in the expected time
but has not developed acute complications
- BUT recurrent rhinosinusitis occurs when episodes of ABRS clear with antibiotic therapy but recur
with each or most upper respiratory infections
-
Symptoms:
- Nasal obstruction/congestion
- Cough- day + night
- Sore throat because of mouth breathing
- Nasal discharge less prominent
** Patients with chronic sinusitis may have a much more subtle presentation, often with nasal congestion as
the main symptom
- Persistent post-nasal discharge
- Slight headache and fatigue because the congestion interferes with restful sleep
Note: Topical decongestants may improve sinus drainage but may cause additional problems with rebound
nasal congestion if used longer than 3-5 days
** If a patient responds favorably to the initial 3-5 days of therapy but only partially responds to a 10-14 day
course of antibiotics, a new type should be used because of potential bacterial resistance
- Use of beta-lactams, cephalosporins, macrolides, or quinolones
16. Infections of the Ear
1- Otitis Externa- inflammation of the skin lining the ear canal and surrounding soft tissue
- Infections due to Staphylococcus aureus or Pseudomonas aeruginosa are the most common Haemophilus influenza B is also a
common cause.
- Symptoms include pain and itching in the ear
- Movement of the pinna or tragus causes pain
- The ear canal is typically grossly swollen
Otitis Media
vii- OM with effusion- is the presence of middle ear fluid after antimicrobial treatment
- Resolution of acute inflammatory signs has occurred
- BUT there is a persistence of a more serous, non-purulent effusion
- Usually resolves within 3-4 weeks
viii- Recurrent acute OM- defined as frequent episodes of acute OM with complete clearing
between each case
- Also defined as 3 episodes of acute OM requiring antibiotic treatment within a 6 month period
ix- Chronic OM with effusion- (serous OM, secretory OM or non-suppurative OM)- is a chronic
condition characterized by persistence of fluid in the middle ear for 3 months or longer
- The tympanic membrane is retracted or concave with impaired mobility and shows no signs of acute
inflammation
- Affected children may be asymptomatic
Note: To distinguish acute otitis media from otitis media externa, signs of inflammation of the tympanic
membrane and symptoms of acute infection must be present
Mobility
i- TM immobile by pneumatic otoscopy- PPV 78%
ii- Tympanometry:
- Normal tympanogram suggests no AOM
- Middle ear effusion
Clinical Presentation
** Children with acute OM have a history of fever and ear pain
2- Rhinitis- 90%
3- Cough- 78%
** Less common cause include: group A streptococcus, Staphylococcus aureus, alpha-hemolytic streptococcus,
pseudomonas aeruginosa
** Respiratory viruses such as RSV, adenovirus, rhinovirus, parainflunza and influenza A also play a role
** Functional obstruction occurs commonly in infants and young children because the tube is less cartilaginous
than in adults
- The tensor veli palatini muscle is also les efficient in younger age groups
** Intrinsic mechanical obstruction of the Eustachian tube occurs as the result of inflammation secondary to a
URI or allergy in patients beyond 5 years of age
Differential Diagnosis
** The most common cause of otalgia (ear pain) is acute OM
** Other causes include
- mastoiditis
- Otitis externa
- Referred pain from the oropharynx, teeth, adenoids or posterior auricular lymph nodes
- Foreign body- in the ear canal can produce symptoms similar to OM
** In acute OM the TM is full or bulging, hyperemic, opaque and has limited or no mobility
- The light reflex is usually distorted or absent
** In persistent or chronic OM, signs of inflammation are usually absent and the TM may be retracted with
limited or no mobility
Laboratory Tests
** Tympanocentesis is the most definitive method of verifying the presence of middle ear fluid and of
recovering the organism responsible for infection
Management
** Oral antibiotics are the first line treatment of acute OM
- Amoxicillin is the first-line drug of choice
- Active against S. pneumoniae and H. influenzae
- Bactrim can be used in penicillin allergic individuals
- Augmentin may be used in cases of resistant organisms
- Course of treatment is 10-14 days
** Frequent bouts of OM require a further search for respiratory allergies, sinusitis, immunologic deficiencies
and anatomic abnormalities (submucosal cleft palate, nasopharyngeal tumor)
** Complications associated with OM are divided into two categories:
i- Extracranial:
- Tympanic membrane perforation
- Conductive and sensorineural hearing loss
- Mastoiditis
- Facial nerve paralysis
- Osteomyelitis of the temporal bone
Predisposing Factors
2- Viral Upper Respiratory Infections- increase the colonization of the nasopharynx with otitis
pathogens
- Viral infections also impair Eustachian tube function by causing both adenoidal swelling and edema of
the tube
- Factors that increase the frequency of viral respiratory infections such as:
- Child care attendance, smoke exposure, absence of breast feeding
- Promote colonization with otitis pathogens and predispose to otitis media
3- Smoke Exposure- Passive smoking increases the risk of persistent middle ear effusion by enhancing
colonization and prolonging the inflammatory response
4- Eustachian Tube Dysfunction- infants born with craniofacial disorders are often affected by AOM
and OME
- EX: Down syndrome, cleft palate
- When the tube is obstructed, a vacuum develops in the middle ear
- This pulls down nasopharyngeal secretions and pathogens into the middle ear
6- Bottle feeding- breastfeeding reduces the incidence of acute respiratory infections, provides IgA
antibodies that reduce colonization with otitis pathogens
7- Genetic Susceptibility
17. Pharyngo-Tonsilitis
** Over 90% of cases of sore throat and fever in children are due to viral infections
Sore Throat
Sore Throat- is a painful inflammation of the pharynx, tonsils or surrounding areas
** The organisms that cause bacterial and viral pharyngitis are present in the saliva and nasal secretions
- Spread from child to child in school is the common mode of transmission
** Most children with sore throat present with sudden onset of pain and fever
- Fever tends to be higher in younger children
- Throat/tonsils are red and the breath may be malodorous
- Headache, nausea, vomiting and abdominal pain may occurs
- Appetite may be decreased
- Activity level may decrease
** In children with the common cold- rhinorrhea and post-nasal discharge are present Common cold is a VIRAL infection - rhinorrhea, cough
common, sore throat
- Cervical nodes may be enlarged and are usually not tender Rhinovirus
- A pharyngeal or Tonsillar exudate is not typical Adenovirus
Coronavirus
Enterovirus (echovirus, cocksackie virus)
**BUT children with streptococcal pharyngitis usually have: Bacterial sore throat:
High Fever
- High fever Tonsillar and post pharynx exudate
- Pharyngeal + Tonsillar exudate Tender, swollen cervical LN
Systematic symptoms - headache, nausea, vomit, abd pain
- Tender cervical lymph nodes
Pathophysiology
** Bacterial and viral organisms produce sore throat by causing inflammation in the ring of posterior
pharyngeal lymphoid tissues (tonsils, adenoids, surrounding lymphoid tissue)
- This ring of tissue (Waldeyer’s ring) drains the oral and pharyngeal cavity
** Viral sore throats may be acquired by inhalation or self-inoculation from the nasal mucosa or conjunctiva
- The local respiratory epithelium becomes infected with the virus and inflammation occurs
** Group A streptococcus and other bacterial organisms directly invade the mucus membranes
Causative agents of viral sore throat:
Viral Infection Rhinovirus
** Viral infections are the most common cause of sore throat in children Adenovirus
Coronavirus
- Most often associated with a URI caused by a rhinovirus Enterovirus
Same as causative agents of common cold
Adenovirus- leads to exudative pharyngitis, frequently in children less than 3 years old
- Pharyngoconjunctival fever is characterized by a high fever, conjunctivitis and exudative tonsillitis Notably, adenovirus 3 causes
pharyngoconjunctival fever
Coxsackie A16 & Coxsackie virus + echovirus (enteroviruses)- are the usual cause of herpangina Painful mouth infection mostly by Coxsackie Virus A
Enterovirus 71 = - Vesicles + ulcers are found on the attention Tonsillar pillars and soft palate (mostly) or B
Hand foot mouth
disease. - May also be found on the pharynx or posterior buccal mucosa Enterovirus target tonsils, soft palate, pharynx - posteriorly
HSV target anterior part of mouth
- Children may have a high fever, irritability and refuse to eat or drink Dehydration may occur in both
HSV- may lead to pharyngotonsillitis BUT this can be distinguished from the enteroviral infections because
HSV almost always involves the anterior portion of the mouth and lips
- AND is associated with a gingivitis (herpes gingivostomatitis)
- High fever and refusal to eat or drink because of the painful lesions can lead to dehydration
EBV- may cause exudative pharyngotonsillitis either alone
- OR as part of the infectious mononucleosis syndrome (fever, malaise, lymphadenopathy,
hepatosplenomegaly) + sore throat
Bacterial Infection
** Group A beta-hemolytic streptococcus is the most common cause of bacterial sore throat in children over 3
years of age
- The pharynx is typically very red and sometimes edematous
- Tonsils are red, enlarged and covered with exudate
- Symptoms: dysphagia, fever, vomiting, headache, malaise, abdominal pain In bacterial sore throat, more constitutional symptoms seen
- Swollen anterior cervical lymphadenopathy and petechiae on the soft palate and uvula are usually seen
Note: The occurrence of a scarlatiniform rash, strawberry tongue and Pastia’s lines indicates scarlet fever
Note: Rheumatic fever and glomerulonephritis are non-suppurative complications of group A streptococcal
infection Pastia's Lines = Classic red streaks associated with Scarlet Fever seen in the crevices of the elbow and underarm
Viral Croup
- Generally affects younger children in the fall and early winter months
- Most often caused by parainfluenza virus
- Other organisms causing croup include: RSV, influenza, rubeola virus, adenovirus, mycoplasma
pneumoniae (above 5-6 years)
- Viral croup most commonly occurs between 3 months and 3 years Occurs in younger children and not in adults because of the
smaller airway of children. The smaller airway close due to
- Inflammation of the entire airway is present inflammation.
- BUT edema formation in the supraglottic space accounts for the main signs of upper airway
obstruction
Presents similar to Bacterial Tracheitis, BUT has a better outcome
** Prodrome of upper respiratory tract symptoms followed by a barking cough and stridor Seal bark occurs due to the inflamed mucosa
being floppy. Inflammation causes the airway
- Fever usually absent or low-grade to close and cause the noisy breathing =
- As obstruction worsens, stridor occurs at rest stridor
- Note: the presence of cough and the absence of drooling favor the diagnosis of viral croup over
epiglottitis
Epiglottitis
- Incidence has decreased with the introduction of the Hib vaccine
- Sudden onset of fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis and stridor
Drooling is due to pain on swallowing
Bronchiolitis
- The most common serious acute respiratory illness in infants and young children
- Characteristically occurs in children < 2 years
- Approximately 80% of all cases occur in the first year of life
- Age of highest incidence is between 2 to 6 months
- Typical Presentation: acute onset of tachypnea, cough, expiratory wheezing after 1-2 days of
rhinorrhea Tachypnea = compensation made to increase the amounts of O2 to be exchanged between the alveoli and circulation
- Respiratory syncytial virus (RSV) is the most common viral cause of acute bronchiolitis
- Next most common cause are the parainfluenza viruses + metapneumovirus
The Bronchial Tree = Trachea > Primary B > Secondary (Lobar) B > Tertiary (Segmental) B > Terminal Bronchioles > Respiratory Bronchioles > Alveolar Ducts Alveolar Sacs
** The usual course of RSV bronchiolitis is 1-2 days of fever, rhinorrhea and cough Late Stages of Bronchiolitis = Wheezing and Air Trapping
- Followed by wheezing, tachypnea, and respiratory distress
- Breathing pattern is shallow with rapid respirations
- Nasal flaring, cyanosis, retractions and rales may be present
- Prolongation of the expiratory phase and wheezing may be present depending on the severity of illness
Risk Factors:
- Age
- Prematurity
- Chronic lung disease
Wheezing & Asthma
** Shortness of breath is usually associated with disorders of the lower respiratory tract: windpipe (trachea) and within the lungs, the
bronchi, bronchioles, and alveoli.
- Pneumonia
- Bronchiolitis
- Asthma
** Recurrent wheezing is a frequent symptom of obstructive airway disease in children. May be caused by:
- Intrinsic or extrinsic compression of the airway Obstructive = Easy In/Hard Out
- Bronchospasm Air comes into the lungs easily. Difficulty for air to be exhaled. Residual air remains.
Restrictive = Hard In/Easy Out
- Inflammation or defective clearance of secretions Air comes in upon inhalation, but the lungs cannot stretch to accommodate it.
Note: Reactive airway disease (asthma) is the most common cause of wheezing in childhood
** Infants may present with apnea, inspiratory and expiratory wheezing, fever and respiratory distress
Note: Infants with recurrent bronchiolitis may have reactive airway disease
** In older children, asthma is the most common cause of persistent or recurrent wheezing
The constriction of smooth muscle + secretion of fluid into the lumen causing narrowing f
** Asthma is a lung disease with the following characteristics: the lumen.
i- Increased airway responsiveness to a variety of stimuli
ii- Reversible airway obstruction
iii- Inflammation of the airways
Clinical Presentation
** Children with asthma may present with acute symptoms of cough and shortness of breath
- Wheezing may be audible
- Some children may have a cough, which may be nocturnal or recurrent as a predominant symptom
- Some patients have symptoms (cough, wheezing) that are precipitated or exacerbated by exercise
Pathophysiology
** Asthma is a chronic inflammatory disorder of the airways. The immunohistopathologic features of asthma
include:
i- Denudation of the airway epithelium
ii- Collagen deposition beneath the basement membrane
iii- Edema
iv- Mast cell activation
v- Inflammatory cell infiltration
Note: Atopy is the genetic predisposition to the development of IgE=mediated response to common
aeroallergens
- Atopy is the strongest predisposing factor for developing asthma People with atopy usually have Allergic Asthma, Rhinitis & Eczema
Primary Malnutrition- insufficient or unbalanced consumption of nutrients that is not related to an underlying
pathophysiologic problem
Secondary Malnutrition- intake is adequate, however there is an underlying pathophysiologic problem which
leads to undernutrition
Classification Systems
Gomez Classification
Gomez Classification- The child’s weight is compared to that of a normal child (50th percentile) of the same
age Does not take into consideration EDEMA
- Useful for population screening and public health evaluations
Note: Gomez system uses weight for age and therefore does not consider the height of the child
Waterlow Classification:
Chronic malnutrition results in stunting. Malnutrition also affects the child's body proportions eventually
resulting in body wastage.
percent weight for height = ((weight of patient) / (weight of a normal child of the same height)) * 100percent
height for age = ((height of patient) / (height of a normal child of the same age)) * 100
Examination
Affect:
- Apathy
- Irritability
Hair Changes
- Alopecia
- Hair loss
- Forest sign Curly hair on top with a straight shaft
- Flag sign bands of discoloration of hair resulting from fluctuations in nutrition. The hypo-pigmented parts signify the periods of malnutrition
- Pluckability
Eyes:
- Sunken eyes
- Jaundiced sclera
- Pale mucus membranes
- White spots in the eyes due to Vitamin A deficiency
- Wrinkling of the cornea
- Dry eyes
- Angular palpebritis
- Keratus cornea
- Periorbital edema
Mouth
- Angular chelosis- due to vitamin B12 deficiency
- Oral thrush
- Ulcers
- Glossitis
- Loss of papillae
- Bleeding gums
- Loss of teeth
Body:
- Dry, flaky skin
- Flaky paint dermatosis
- Crazy pavement dermatosis
- Pretibial edema
- Palpable pitting edema
- Rickettsia rosary- most common on the lower 4-6 ribs
- Hepatomegaly- due to fatty liver infiltration
Dehydration vs Malnutrition
Note: Malnourished children are usually totally potassium-depleted with an increase in intracellular sodium
- WHO solution + sucrose has decreased sodium and more potassium WHO solution = ORS (Oral Rehydration Salts)
Phases of Recovery
1- Resuscitation Phase- stabilize the child at the cellular lavel, so that normal cellular responses can take
place
- Assess issues of hypovolemia This phase is complete when all the issues are absent
- Underlying infections
- Edema
2- Rapid Catch-up Growth Phase- increase calorie density of feed. Reaching the appropriate weight for
height is the target at this time
3- Home
** Children are at increased risk for episodes of dehydration for a number of reasons
- Young children have 3-4 x the body surface area per unit body weight compared with adults
- Therefore they have relatively higher fluid needs
- As a result it is much easier for children to become dehydrated in the face of decreased intake or
increased losses that accompany common childhood illnesses
** In addition children/infants are dependent on caregivers and therefore are unable to increase their own fluid
intake in response to thirst independently
History
** The history should focus on the cause of the dehydration
- Type and amount of oral intake
- Duration, quality and frequency of the vomitus and/or diarrhea
- Presence of blood in the stool
- Presence or absence of a fever
- Frequency of urination
- How much did the child weigh on the last visit to the physician
** The most accurate way to assess the degree of dehydration is to compare current weight to a recent pre-
illness weight
- In acute dehydration the loss of weight is mainly due to fluid loss
** Oral rehydration therapy is preferred for children with mild dehydration and most children with
moderate dehydration
** Parenteral fluid therapy should be used in children with severe dehydration, when oral therapy has failed
- Also in children in shock or impending shock
- Anatomic defect such as pyloric stenosis or ileus
20. Vomiting
Vomiting- is defined as the forceful ejection of the stomach contents though the mouth
- Mechanism involves a series of neurologically co-ordinated events under the control of the CNS
Regurgitation- is the effortless bringing up of one or two mouthfuls of food without distress or discomfort
- Freqeunt symptom of gastroesophageal reflux
Exclusive Breastfeeding- Feeding infants with breast milk only for the first 6 months of life
- Giving no other food or drink
- After which appropriate and adequate complementary foods should be introduced gradually
- Breastfeeding should be continued up to and beyond two years of age
Step 1:
- Have a written policy that is routinely communicated to all health care steps
Step 2:
- Train all health care staff in skills necessary to implement this policy
Step 3:
- Inform all pregnancy women about the benefits and management of breastfeeding
Step 4:
- Help mothers initiate breastfeeding within half-hour of birth
- Give mother the baby to hold skin-to-skin immediately after birth and for at least one hour if possible
Step 5:
- Show mothers how to breastfeed and how to maintain lactation even if they are separated from their
infants
Step 6:
- Give newborn infants no food or drink unless medically indicated
Step 7:
- Practice rooming-in allow mothers and infants to remain together 24 hours a day
Rooming-in is the practice of having the baby in a crib near the mother and father. This promotes bonding with the new born.
Step 8:
- Encourage breastfeeding on demand
- Whenever the baby wants for as long as the baby who is well attached wants
- Waking the baby if he sleeps too long
- That is giving at least 6-8 feeds in 24 hours to a large baby or 10-12 feeeds to small or jaundiced babies
in 24 hrs
Step 9:
- Give no artificial teats or pacifiers (soothers) to breast-feeding infants
Step 10:
- Foster the establishment of breast-feeding support gropus and refer mothers to them on discharge from
the hospital or clinic
Benefits of Breastfeeding
- Provides optimal nutrition
- Reduces incidence and severity of infections
- Protects against food allergies and eczema
- Increased cognitive, visual development
- Promotes bonding
Nutrient Content
Foremilk- the milk released at the beginning of a feed is watery, low in fat and high in carbohydrates
RELATIVE to the creamier hindmilk released as the feed progresses Comes in 3-5 days
** The nutrient content is relatively independent of maternal diet except for fluid intake
- Carbohydrates- lactose, oligosaccharides
- Fat- Tgs, fat soluble vitamins
- Protein- casein 30%, whey 70%, immune proteins
- Minerals
** Compared with cow’s milk, breast milk has a lower renal solute load as welll as:
- Higher carbohydrates Way more Whey and Carbohydrates than cows milk
- Lower protein
- Higher whey %
- Lower Fe
- Lower Fe
- Lower Ca
- Lower PO4
Breast Anatomy
- Alveoli are small sacs made of milk-secreting cells
- Prolactin makes the cells produce milk
- Muscle cells contract and are acted on by oxytocin
Note: The difference between small and large breasts is fat content.
- The internal duct structure is the same
Prolactin
- Prolactin is secreted after the feed to produce milk for the next feed
- Baby sucking stimulates the release of prolactin in the blood
- More prolactin is secreted at night
- Suppresses ovulation
- Most prolactin is in the blood 30 mins after the feeding and produces milk for the next feeed
Oxytocin Reflex
- Oxytocin works before or during feed to make milk flow
- Oxytocin reflex can be stimulated before actual sucking by thinking lovingly of baby, sounds of baby,
sight of baby
- The reflex can be hindered by worry, stress, pain, doubt
Note: The presence of milk in the breast ie a breast full of milk acts as an inhibitor and stops the secretion of
further milk
Baby Reflexes
1- Rooting- when something touches the lips, the baby opens mouth and puts tongue down and forward
2- Sucking- When something touches the palate the baby sucks
3- Swallowing Reflex- as the mouth fills with milk, the baby swallows
Good Attachment
- Taken much areola and underlying tissue into the mouth
- Stretched the breast tissue to form a teat and the nipple forms about 1/3 of the teat
- Therefore the baby is suckling from the breast NOT solely the nipple
- Tongue cupped round nipple
- More areola is above the top than below the bottom lip
- The baby’s mouth is wide open
- Lower lip turns outwards
- Baby’s chin touches the breast
Cradle Types
Cradle Hold- Same arm, supports while drinking from the same breast
Cross Cradle Hold- especially useful for young infants who have not figured out how to breastfeed yet
Football Hold- works well have large breasted mothers and those that need to avoid the baby being on their
abdomen
Australian Hold- recommended when a mother has too much milk or the flow of milk is too fats
- Because one is reclined backwards or lying down, gravity will help your milk come out slower
- Therefore less chance of baby gagging on excess milk
Milk Expression
i- Engorgement
ii- Very full breasts
iii- Ensuring that the baby gets enough (prematurity)
iv- Need for measurement of milk
v- Sick mother
vi- Separation
vii- Return to work