APPROACH TO CHILD

WITH GENERALIZED
EDEMA
                                          Dr. Sundal Aijaz 
GENERALIZED EDEMA-ANASARCA

◦Fluid accumulation in body tissues extra vascularly

1. Cardiac failure
2. Renal disease
3. Liver disease
4. Hypoproteinemia
5. Allergic reactions
◦ Swelling
◦ Shiny skin
◦ Enlarge abdomen
◦ Sudden weight gain
◦ Puffy eyes
◦ Severe edema that may cause
severe leg pain, feel heavy
and difficult to walk
◦ Ulcer may also develop on skin
of leg since severe leg edema
can interfere with the blood
flow
Starling's forces:
hydrostatic
pressure_ colloid
osmotic pressure
hydrostatic pressure:
pressure of blood
against the wall of
blood
vessels.pressure
exerted by the blood
will become lower
as the blood moves
along the capillaries,
from the arterial to
venous end.
Colloid osmotic
pressure: exerted by
proteins in the blood
plasma or interstitial
fluid. 
CARDIAC EDEMA
◦ Right sided heart failure-systemic congestion and generalized edema
◦ Left sided heart failure – initially pulmonary congestion and edema later
generalized edema
◦ Pitting edema
◦ Dependent edema: Ambulant-maximal over ankles and feet(pedal)
                                               - worse towards end of day 
                                               -clears up with recumbence
Bed ridden- maximal over sacrum
Legs         Face          Ascites
◦ Symptoms of CCF such as orthopnea, paraoxysmal nocturnal dyspnea in
older children and poor weight gain,
Feeding difficulties, excessive sweating,
Bluish episodes and respiratory distress in
Infants.
◦ Signs: cardiomegaly, pallor, cool extremities
Weak pulse, murmur, displaced apex
Beat, elevated JVP
Renal Edema
◦ Nephrotic , Nephritic, Renal failure
Nephrotic:
- severe,generalized,dependent
- loose connective tissue, subcutaneous tissue, visceral organs
- face(periorbital) legs(with scrotal swelling) ascites
- Other features –massive proteinuria, Hypoalbuminemia,
hypercholesterolemia
- Frothy urine suggests nephrotic syndrome
◦ Acute nephritic: -mild
-loose connective tissue
(eyelids and face, ankles, genitalia)
-moderate proteinuria
-Signs and symptoms of chronic insufficiency such as anemia, growth
retardation, uremic symptoms such as nausea and vomiting
◦ Both –more on waking up after sleep
-generalized, pitting
Liver Disease
◦ Ask for history of fever, anorexia, vomiting,
Abdominal pain, progressive jaundice,
Fetor hepaticus , bleeding manifestations,
Clay color stool, black tarry stool, hematemesis,
Pruritis and abdominal distension.
Stigmata of chronic liver disease such as palmer erythema, clubbing and
Spider naviae.
◦ Chronic liver disease
- Decreased protein synthesis
- Ascites legs face
- Pitting edema
Protein losing enteropathy
◦ History of diarrhea, steatorrhea , foul stools, failure to thrive, repeated
infections and recurrent abdominal pain.
◦ Detailed dietary history for possible cow milk allergy and gluten
hypersensitivity.
◦ Assess for complications of anemia, malnutrition and viatmin deficiency.
◦ This condition should be considered in every case of unexplained edema
(even without diarrhea) especially when it is associated with
hypoproteinemia.
Protein energy malnutrition
(Kwashiokor)
◦ History of anorexia, lethargy, diarrhea, vomiting, failure to thrive,
susceptibility to infections, night blindness, inadequate or inappropriate dietary
history especially prolonged lack of protein.
◦ Growth parameters, irritability, skin changes, hair changes, signs and
symptoms of micronutrient deficiency.
Allergic reactions
◦ Edema usually mild, commonly periorbital
◦ History of allergen exposure such as medications, animal dander,
food preservatives and coloring.
◦ Associated rashes such as urticarial
◦ Assess for steven-johnson reaction
Investigations
◦ CBC : normochromic normocytic anemia suggest chronic disease,
megaloblastic anemia suggests B12 and folate deficiency from small
bowel disease
◦ urine dipstick and microscopy: proteinuria, hematuria and casts are
indicative of renal disease.
◦ RFT: raised serum urea and creatinine are indicative of renal disease.
◦ LFT: hypoalbuminemia, hyperbilirubinemia and elevated liver enzymes.
◦ Chest xray ,ECG, Echocardiography
Management
◦ General measures
1. Dietary management : Na restriction and fluid restriction to 2/3
of maintenance depending on the severity of edema.
2. Diuretics therapy
3. Bed rest
4. Specific therapy according to the cause