paediatrics notes 3 update pdf

Umwangange. Paediatrics, BSNM 2013

CHAPTER I. DISEASES AFFECTING VARIOUS SYSTEMS

I. RESPIRATORY SYSTEM

A. ACUTE BRONCHITIS

DEFINITION

Acute bronchitis is infection and inflammation of the bronchi. It is a common disease that can

occur at any time of the year, but most cases happen in the winter months. It is most common in

infants and young children.

CAUSES & RISK FACTORS

Acute bronchitis is the result of a viral( e.g. Respiratory syncitial virus) or bacterial infection

(e.g. Hemophilus influenza) which causes inflammation of the airways; bronchi. Mycaplasma

pneumoniae is a common cause in children older than 6 years.

Risk factors:

- Air pollution exposition

- Lung irritants

- exposition to cold

SIGNS & SYMPTOMS

Cold-like symptoms (headache, malaise, rhinorrhoea…)

Painful cough : Dry cough in early stages and productive cough (with purulent sputum)

usually in later stages (in 2 to 3 days).

Children younger than 5 years rarely expectorate, sputum is usually seen in vomitus (i.e.

posttussive emesis)

Wheezing

Fever (in case of bacterial bronchitis )

Generally sick

Trouble breathing: shortness of breath

Noisy breathing (rattling sound in the chest)

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DIAGNOSIS

- Making a diagnosis of acute bronchitis begins with taking a thorough medical history,

including symptoms, and exposure to lung irritants.

- A physical examination is also performed and includes listening with a stethoscope to the

sounds that lungs make during respiration. Lung sounds that may point to a diagnosis of acute

bronchitis include wheezing, or crackling sound and decreased lung sounds.

- A chest X-ray and CT scan of the chest can help to exclude the diagnosis of pneumonia.

- Blood or sputum culture if antibiotic therapy is under consideration

DIFFERENTIAL DIAGNOSIS

Differential diagnosis include but are not limited to:

- Pneumonia

- Upper respiratory tract infections such as rhinitis

- influenza or cold flu

TREATMENT

- The goal of treatment of acute bronchitis is to control symptoms, such as fever, cough, and

shortness of breath, and to minimize the development of serious complications, such as

pneumonia.

The first step in treatment is prevention. The risk of developing acute bronchitis can be reduced

by avoiding air pollutants, cold…

- Ensure that the child has adequate oxygenation.

- General measures include:

Rest

Fluids for adequate hydration

Pain relief and Antipyretics: Paracetamol, Ibuprofen

Cough suppressant: such as Codeine, Bronchalene in case of dry cough,

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Antibiotics : Such as Amoxycillin, in case of bacterial bronchitis. The combination of

Amoxycillin and clavulanic acid (Augmentin) should also be used. Erythromycin is used

in case of allergy or resistance to penicillin (amoxicillin)

Physiotherapy: respiratory exercise, postural drainage

Humidifier: to try to thin out sputum

Avoid very cold weather

COMPLICATIONS

- Bronchopneumonia

- Acute respiratory failure

B. PNEUMONIA

Pneumonia, inflammation of the pulmonary parenchyma, is common throughout childhood but

occurs more frequently in infancy and early childhood. Clinically, pneumonia may occur either

as a primary disease or as a complication of some illness.

Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an

estimated 1.2 million children under the age of five years, accounting for 18% of all deaths of

children under five years old worldwide (WHO, 2012)

Morphologically, pneumonias are recognized as follows:

Lobar pneumonia: all or a large segment of one or more pulmonary lobes is involved.

When both lungs are affected, it is known as bilateral or “ double” pneumonia.

Bronchopneumonia: begins in the terminal bronchioles, which become clogged with

mucopurulent exudates to form consolidated patches in nearby lobules; also called

lobular pneumonia.

Intertitial pneumonia: The inflammatory process is more or less confined within the

alveolar walls (interstitium) and the peribronchial and interlobular tissues.

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CAUSES

Viral: respiratory syncytial virus is the most common viral cause of pneumonia.

Atypical (mycoplasma)

Bacterial: pneumococcus/ Streptococcus pneumoniae is the most common cause of

bacterial pneumonia). Haemophilus influenza type b (Hib) is the second most common

cause of bacterial pneumonia.

Fungi (e.g. histomycosis, coccidiomycosis… )

In HIV- infected infants, Pneumocystis jiroveci is responsible for at least one quarter of

all pneumonia deaths.

Aspiration of foreign substances

RISK FACTORS

Compromised immune systems: in case of malnutrition, HIV infection, measles…

Environmental factors: indoor air pollution, living in crowded homes, parental

smoking…

PATHOLOGY/ EVOLUTION OF PNEUMOCOCCAL PNEUMONIA

Pneumococcal pneumonia evolves through a series of pathologic changes:

- The initial phase is one of edema: presence of a proteinaceous exudates and often of bacteria

in the alveoli.

- The 2nd

phase, red hepatization: The presence of erythrocytes in the cellular intraalveolar

exudate gives this second stage its name, but neutrophils are also present and are important from

the standpoint of host defense. Bacteria are occasionally seen in cultures of alveolar specimens

collected during this phase.

- The third phase, gray hepatization: no new erythrocytes are extravasating, and those already

present have been lysed and degraded. The neutrophil is the predominant cell, fibrin deposition is

abundant, and bacteria have disappeared. This phase corresponds with successful containment of

the infection and improvement in gas exchange.


-The final phase, resolution, the macrophage is the dominant cell type in the alveolar space,

and the debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory

response.

This pattern has been described best for pneumococcal pneumonia and may not apply to

pneumonias of all etiologies, especially viral or Pneumocystis pneumoni

CLINICAL MANIFESTATIONS

Cough. Newborns (neonates) with pneumonia rarely cough.

Fever, chills

Tachypnea: the absence of tachypnea is a strong indication that the child does not have

pneumonia

Wheezes and/or crackles on auscultation

In severe cases there is the use of accessory muscles, retractions including sub-costal and

inter-costal, sub-xyphoid, nasal flaring

Hypoxemia may be present, but is often a late sign.

Prostration. Very severely ill infants may be unable to feed or drink and may also

experience unconsciousness, hypothermia and convulsions.

These symptoms may be preceded by minor Upper Respiratory Infections (URIs)

symptomatology including low- grade fever and rhinorrhea.

DIAGNOSTIC

The clinical manifestations and the physical examination can make a diagnosis of

Pneumonia.

Leucocytosis (WBC > 15,000-20,000/mm3) in association with fever of 39

0C often

suggests a bacterial etiology.

Blood culture especially in severe pneumonia and in infants under 3 months of age.

Gram stain and culture on respiration secretions (sputum, bronchoalveolar lavage, pleural

fluids) can be helpful

Chest Radiography to confirm the presence and location of pneumonia; however, a

normal chest X-ray does not rule out pneumonia.


MANAGEMENT

- Hospitalization: its indication includes Oxygen requirement (sat. < 95%), infants < 2 months,

presence of moderate to large pleural effusions and in other very severe cases.

- Antibiotics in inpatient:

. Ampicilline + Gentamycine for neonates 0-30 days

. Cefotaxin is antibiotic of choice in children between 1 month and 5 years

. If Chlamydia trachomatis or Brodetera pertussis are suspected, give a Macrolide e.g.

Erythromycine

. For Hospitalized children over 5 years: Cefotaxin+ Erythromycin

The duration of therapy depends on the patient’s response but in general is 10-14 days for

children up to 3 months of age and 7-10 days for children older than 3 months.

- For outpatient:

. Children under 5 years: Amoxycillin in High dose (80-90mg/kg/day)

. If the child is vomiting, an initial parental dose of Ceftriaxone is given

. For children over 5 years, give a macrolide (Erythromycin)

- In case of viral pneumonia, there is no need of antibiotic.

PREVENTION

- Preventing pneumonia in children is an essential component of a strategy to reduce child

mortality. Immunization against Hib, pneumococcus, measles and whooping cough (pertussis) is

the most effective way to prevent pneumonia.

- Adequate nutrition: starting with exclusive breastfeeding for the first six months of life.

- Prevent environmental factors

- In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk

of contracting pneumonia.


C. BRONCHIAL ASTHMA

Asthma is the most common chronic disorder in children and adolescents. About 5 million of

children under 18 years have asthma. This includes an estimated 1.3 million children under the

age of 5 years.

PATHOPHYSIOLOGY

Asthma is a chronic inflammatory disorder of airway in which many cells play a role, including

mast cells and eosinophils. The symptoms are associated with airway obstruction

(bronchoconstriction) due to inflammation with mucosal edema leading to bronchospasm. The

airway narrowing is often reversible either spontaneously or with treatment, and causes an

associated increase in airway responsiveness to variety of stimuli as well as bronchial

hypersecresion.

Risk factors

exposure to tobacco smoke

Previous allergic reactions: food allergies, allergic rhinitis, allergic sinusitis, eczema

Family history of asthma, family history of allergy

Exposure to air pollution

Recurrent respiratory viral infections

Triggers

The asthma triggers vary from child to child and can include:

Viral infections such as the common cold

Exposure to air pollutants, such as tobacco smoke

Allergies to dust mites, pet dander, pollen or mold

Physical activity

Weather changes or cold air

Emotions and stress

Sometimes, asthma symptoms occur with no apparent triggers.


CLINICAL FEATURES

Cough

Cough at night or with exercise

Allergic symptoms such as rhinitis, sinusitis, eczema

Wheezing

Episodic wheeze, ronchi

Shortness of breath

chest tightness

Symptoms increase in case of aeroallergens or exercise, they worsen at night, awakening

the patient.

THERAPY

- Assess the severity: intermittent, mild persistent, moderate persistent, severe persistent.

- Pharmacological management: the use of agents to control and agents for quick relief of

symptoms.

Control agents: inhaled corticosteroids (e.g. Fluticasone, Beclomethasone…),

long acting Beta- agonists/bronchodilators (e.g. Salmeterol…),

Theophylline/Aminophylline, Leucotrienes modifiers (e.g.Montelukast/

Singulair), anti-immunoglobulin E (e.g. Omalizumab)

Relief medications: short- acting bronchodilators (e.g. Albuterol/Salbutamol), oral

and parenteral corticosteroids (e.g. Prednisolone)

- Acute asthma management includes the use of B-Agonist for a quick ;When B-agonists

are ineffective or required more than four times a day give bronchodilatator e.g.

salbutamol add oral corticoids (1-2mg/kg/day for 3-5days eg dexamethazone,

prednisolone.

- In case of acute severe asthmatic episodes (Status asthmaticus): Correct the significant

hypoxemia with supplemental oxygen. Mechanically assisted ventilation may be required

in alveolar hypoventilation.


PROGNOSIS

There is no cure for asthma. Symptoms sometimes decrease over time. With repetitive attacks,

school absenteeism is one of the outcomes.

II. GASTRO- INTESTINAL SYSTEM

A. DIARRHEA

Diarrhea is loss of watery stools (or bloody) for more than 3 times a day (more than 5 times a

day for the neonates and small infants). Acute diarrhea is a common problem that usually lasts 1

or 2 days, it can be prolonged and persist for more than 2 days and poses the risk of dehydration.

Chronic diarrhea may be a feature of a chronic disease.

Diarrhea is a common gastrointestinal problem during infancy and early childhood. In

developing countries, diarrhea causes around two million child deaths annually.

CAUSES OF DIARRHEA

Acute diarrhea

Bacterial infections. Several types of bacteria consumed through contaminated food or

water can cause diarrhea. Common causes include Campylobacter, Salmonella, Shigella,

and Escherichia coli (E. coli).

Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus,

cytomegalovirus, herpes simplex virus, and viral hepatitis.

Food intolerances. Some people are unable to digest food components such as lactose;

the sugar found in milk, infants can also have milk-protein allergies.

Parasites. Parasites can enter the body through food or water and settle in the digestive

system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica

Reaction to medicines. Antibiotics, cancer drugs (chemotherapy), and antacids

containing magnesium can all cause diarrhea.

Intestinal diseases. Inflammatory bowel disease, colitis, Crohn’s disease, Congenital

aganglionic megacolon often lead to diarrhea.


Functional bowel disorders. Diarrhea can be a symptom of irritable bowel syndrome.

Chronic diarrhea

Diarrhea that persists longer than 4 weeks is considered to be chronic.

SIGNS & SYMPTOMS

-Frequent elimination: liquid stool (watery or bloody) accompanied by cramping, abdominal

pain, nausea. Depending to the cause, the child may have fever, vomiting.

DIAGNOSTIC

Stool culture

Stool examination

Blood tests

Sigmoidoscopy/ colonoscopy

COMPLICATIONS

Dehydration is the principal complication of diarrhoea,

Malnutrition in case of chronic diarrhoea

Rectal prolapse in case of repetitive diarrhoea or chronic diarrhoea.

MANAGEMENT OF DIARRHEA

- Prevent the dehydration by giving ORS (Oral Rehydrating Solution)

-Teach the mother on hygiene and sanitation

-To treat aetiology: e.g anti-infectious medication…

- Zinc supplementation in children over 6 months: in developing countries, many children have

zinc deficiency. Zinc sulfate reduces the duration of diarrhoea and accelerates appetite

- Treat Dehydration

Table 1: Clinical assessment of degree of dehydration (Goldman et al., 2008)


Degree of

dehydration

Mild

(5-7% body weight)

Moderate

(7-9% body weight)

Severe

(>10% body weight)

Fontanelle Slightly sunken Very sunken Very sunken

Mucous membranes Slightly humid Dry Very dry

Skin turgor Normal Slightly

decreased(<2sec)

Markedly

decreased(≥2sec)

Capillary refill time Normal (<3 seconds) Normal (<3 seconds) Delayed (≥3 seconds)

Urine output Normal Slightly decreased Decreased or absent

Mental status Normal Slightly fussy Irritable or lethargic

Based on the degree of dehydration, the following approach to management has been suggested:

Table 2: Management of Dehydration

Degree of

dehydration Management

Mild Home-based treatment

Moderate

Oral rehydration as the child needs; and give 50-100 ml for every watery stool

(<12months), 100-200ml for every watery stool (≥ 12months)

oral rehydration therapy (ORS 75ml/kg in 4 hours) if the child vomits use

nasogastric tube

Reassess, if the child is now in mild dehydration, adjust the treatment.

Severe

Admit patient, do bloodwork - give 30 mL/kg bolus IV fluids over 1 hour

(<12months) or over 30min (≥12months), check pH, bicarbonate, nitrogen.

Continue IV as required: 70ml/kg in 5hours (<12months) and 70ml/kg in 2h 30

(≥ 12months). Assess the patient every one hour in less than 12 months children

and every 30 minutes in 12months and more.(Use surveillance sheet)

Oral rehydration therapy include ORS with electrolytes, breastmilk and not tea, sugar drinks

such as apple juice and other juices, homemade remedies.

In a child, the normal fluid requirement (ORS) per 24 hours (maintenance therapy) is

approximately:

100 ml/kg for the first 1–10 kilograms of body weight

50 ml/kg for the next 11–20 kilograms of body weight

20 ml/kg for every kilogram of body weight exceeding 20 kg.

Example: fluid requirement in a child weighing 26 kg is 10 × 100 ml + 10 × 50 ml + 6 ×

20 ml = 1 620 ml. ( From EBM Guidelines)


Indications for referral to hospital (From Evidence-based medicine Guidelines )

The child is referred if even one of the following criteria is met:

→ Age below 6 months

→ Profuse diarrhoea or vomiting, poor general condition

→ Dehydration of 8% or more (at least moderately severe dehydration)

→ Diarrhea lasting for more than 5 days (the general condition and loss of weight are

decisive factors)

→ Colicky abdominal pain (and sudden ceasing of the diarrhea): intussusception?

→ Bloody diarrhoea

→ Inability to treat the child at home

Correction of the estimated dehydration is often possible by administration of a corrective

solution through a nasogastric tube at the outpatient department of a hospital. Afterwards,

the child is examined and weighed and can usually be discharged for follow-up care at

home.

If the child is in shock when referred, infuse Ringer solution 20 ml/kg in 15 minutes.

In a hospitalized patient, fluid balance parameters, CRP, basic blood picture and blood

gas analysis are examined.

B. PARASITOSIS

ASCARIASIS

This is caused by ascaris lumbricoides. It is seen more commonly in the children between the

age of one and five years with lower socioeconomic status (poor hygiene). It is transmitted

through contaminated food, water, hands, and utensils.

Manifestations

Slight fever due to larvae;

Ascaris pneumonia due to larvae in the lungs with dry cough (Lo ffler syndrome);

Diarrhoea, abdominal pain and irritability

Loss of appetite, loss of weight

Diagnosis

Stool examination: eggs of ascaris in the stool


Complications

In heavy infections, a large bolus of entangled worms can cause pain and small-bowel

obstruction, sometimes complicated by perforation or volvulus.

A large worm can enter and occlude the biliary tree, causing biliary colic, cholecystitis,

cholangitis, pancreatitis, or (rarely) intrahepatic abscesses.

Treatment: Mebendazole.

Prevention: - Hygiene (use of proper water to drink, to clean fruits and vegetables...)

- Encourage routine hand washing (e.g. after the toilet, before eating) in children

also should minimize infestation

- use of sanitary latrines minimize infestation

-For children under 5 years, give mebendazole 500mg every 3 months.

OXYUROSE

It is caused by Enterobius vermicularis and is transmitted because of unsanitary living

conditions in the school, hostel and families.

It is transmitted through contaminated soil, fingers, flies.

manifestations

General symptoms found:

loss of weight

lack of appetite

abdominal pain

Itching at anal region.

diagnosis

Stool examination.

treatment


- Mebendazole 100mg is prescribed and administered twice a day.

-It is advisable to treat whole family at the same time.

-Hygiene, cut finger nails to avoid sores due to itching

ANCYLOSTOMIASIS

Is commonly found in children of rural area or in the urban area where children live in the

neighbourhood of field or open grounds. it is caused by Ancylostoma duodenale or Necator

americanus.

The infective larvae enter the human skin through hair follicles.

manifestations

- Epigastric pain;

- Fatigue and weakness;

- Anemia should be present

Diagnosis

- Stool examination

- Eosinophilia may be found.

Treatment

- mebendazole (500 mg once), and pyrantel pamoate (11 mg/kg for 3 days).

- Oral Iron in case of mild iron-deficiency anemia.

- Severe hookworm disease with protein loss and malabsorption necessitates nutritional support

and oral iron replacement.

prevention

- Use of the sanitary latrines helps to prevent the spread of the infestation.

- Habit of using a foot wear helps to prevent the contact with the soil contaminated with worms,

in the open fields.


AMOEBIASIS

It is caused by Entamoeba hystolitica and transmitted through ingestion of contaminated water,

food, hands...

Manifestations

Diffuse lower abdominal pain

Dysentery: diarrhoea with mucus stool accompanied by back pain after defecation

Fever is less common

Diagnosis

Stool examination

Treatment

Metronidazole

C. CONSTIPATION

Functional constipation in childhood is currently defined by Rome criteria as 12 weeks (which

need not to be consecutive) over 12 months of hard stool, sensation of incomplete evacuation or

fewer than three defecations per week.

Physiology

Although breast-fed infants are less likely to develop constipation than those fed cow milk-

based formulas their normal stool frequency can vary widely from seven per day to one every

7days.

Normal stool frequency ranges from an average of four per day during the neonatal period to two

per day by one year of age.

Diagnosis: Functional constipation is clinical diagnosis that can generally be made on the basis

of typical history and an essentially normal physical examination including one of the rectal

examination is a key part of the initial evaluation.


Treatment

Education involves a clear explanation, of the disorder to the parents.

Oral polyethylene glycol is better tolerated if administrated with metoclopramide to enhance

gastric empting.

III. URINARY SYSTEM

A.WILMS TUMOUR

Wilms tumour is the tumour of the kidneys, that affect 1/10000 children younger than 15 years

of age.

It is associated with multiple congenital abnormalities and in some cases with identified

syndromes:

Aniridia (absence of iris) 1%

WAGR ( Wilms tumour, aniridia, genitourinary malformation, and mental retardation)

Deny Drash Syndrome (Wilms tumour, pseudohermaphroditism, and glomerulopathy)

Beckwith-Wiedemann Syndrome (BWS) (macroglosia, gigantism, umbilical hernia)

Trisomy 18

Genitourinary anomalies (5%)

The exact cause is not known. It may be unilateral or bilateral. In most cases, the tumour is

vascular, soft in character.

Manifestation

A firm abdominal mass (common)

Abdominal pain (common)

Hypertension (less common)

Fever (less common)

Haematuria (less common)

Anaemia (less common)

The neoplasm metastasises early, in the perirenal tissue, lymph nodes, the liver, the diaphragm,

abdominal muscles and the lungs.

Staging

Stage I: Tumour limited to the kidney and completely excised

Stage II: Tumour beyond the kidney but completely excised


Stage III: Residual non-hematogenous tumour confined to the abdomen

Stage IV: Hematogenous metastases ( lungs, liver, bone, brain)

Stage V: Bilateral kidney involvement at diagnosis.

Investigation

Abdominal CT and Scanner, MRI

Intravenous pyelography to determine the tumour and assess the kidneys

Urinalysis

Blood urea Nitrogen, Uric acid and alkaline phosphates

Biopsy

Management

- If unilateral tumour: chemotherapy: Adriamycin, vincristine or doxorubicine for 52

weeks followed by nephrectomy

- If bilateral tumours : • Partial nephrectomy and chemotherapy

• Radiotherapy

ACUTE GLOMERULONEPHRITIS

Acute gromerulonephritis is a glomerular disease that can affect children. It is more common in

the age group of 2 to 10 years. It is immune complex disease due to antigen- antibody reaction

following haemolytic streptococcal infection, the antibodies affect the glomerulus causing

proliferation and swelling of endothelial cells, which increase the glomerular capillaries

permeability and lead to hematuria and proteinuria. The amount of the glomerulus is reduced and

it allows the passage of the blood cells and proteins into filtrate.

Manifestations

The symptoms develop about 1 to 3 weeks after the streptococcal infection.

Oedema start with the per orbital oedema in the morning, edema of the ankles, feet, and

occasionally ascites or pleural effusions

Urine out put is decreased with the high colour urine resembling black tea or coca-cola

due to lysis of red blood cells


Hypertension may be present, and may cause headache, vomiting, somnolence, and other

central nervous system manifestations, including seizures.

The fever may or not be present

Children look pale, lethargic, and irritable

Children may complain of a headache

Gastrointestinal disturbances may occur( abdominal pain)

The most severely affected children develop acute renal failure with oliguria.

investigations

1. Urine examination for:

-hematuria

-albumin

-white blood cells and epithelial cells

2. Blood examination for:

-urea nitrogen and creatinin

-Serum albumin

3 .Anti sreptolysin o titer (ASLO)

management


The treatment is symptom-specific

steroids to minimize immune response

Antibiotics, such as long acting penicillin may be given to treat infection

Antihypertensive drugs may be prescribed to control the hypertension

magnesium sulphate may be prescribed in the encephalopathy to reduce cerebral oedema

sedatives may be required in restless patients

Rest may be required for two to four weeks

The vital signs should be observed to detect early signs of complications

Observations of the intake and output is important

salty food items should be avoided

Salty restricted regular food may be allowed,

Fluid should be supplied according to the prescription. The parents should be explained

about the accurate fluid intake.

Recreational facilities and play in the bed can help to divert the children’s mind.

NEPHROTIC SYNDROME

Nephrotic syndrome is a clinical state in which a group of symptoms can be developed in many

renal diseases, where there is increased glomerular permeability to pass plasma proteins.

Proteinuria increases and plasma proteins decrease.

Main characteristics of nephrotic syndrome are oedema, proteinuria, hypoalbunaemia, and

hypercholesterolemia.

Manifestations

Progressive gain in weight, oedema around the eyes, puffiness of the face which may become

generalized. If ascites increase, the child may become breathless

Vomiting, anorexia, and diarrhea may occur due to poor absorption because of the oedema of

the gastrointestinal mucosa.

Children become irritable and get easily fatigued

Foamy urine

Urine output decreases.


Recurrent infections may occur.

Investigations

Urine analysis for proteins

Blood for total serum protein and albumin and globulin levels

Erythro sedimantation rate

Serum cholesterol

Management

Immunosupressive drugs like cyclophosphamide, Levamisole are prescribed in case of

relapses

Diuretics are used to relieve oedema (e.g furosemide)

Antibiotics may be used to treat the infection

Bed rest is required during the stage of oedema

Diet should be low in sodium and high in proteins

The fluid intake requirement is calculated according to the output and weight of the child

Observation of early signs of infection is necessary, because these patients have low

resistance.

Daily urine examination for albumin is required.

Nutritional needs should be met with the diet containing high protein, for example eggs,

milk, soy bean, and ground nuts

IV. TEGUMENTARY SYSTEM (oral candidosis, scabies, psoriasis).

PSORIASIS

Psoriasis is a chronic inflammatory skin disorder with a prevalence of 1-3% in the general

population with one –third of individuals presenting before 20 years of age.

Genetic, immunologic, environmental and infectious factors all play a role in the pathogenesis of

psoriasis.

clinical features and differential diagnosis


Plaque type in the most common form of psoriasis seen in children and adult.

Lesions are erythematous, well-demarcated asymptomatic plaques and can be localized

or generalized on any body site. Scalp is a common site of involvement. Nails can be

involved with pitting, yellowing, subungual hyperkeratosis.

Arthritis, typically of the distal interphalangeal joints occurs in a small percentage of

children with psoriasis.

Streptococcal infection may be a trigger for appearance of a disease

The differential diagnosis includes seborrheic dermatitis, atopic dermatitis and bacterial

folliculitis (pustular variant)

Treatment and Prognosis

topical corticosteroids are used twice daily One is applied in the morning and the other is

applied in the evening

.Topic refined preparations such as liquor carbonic detergents can be combined with

corticosteroids and used once or twice daily.

SCABIES OR ITCH

Definition

Scabies are very tiny parasites (0.33mm in length) almost invisible to the naked eye, that live in

the folds to the skin, digging short, thin burrows in which they deposit their eggs, causing in this

way, irritation and itching. They do not suck blood but are nourished by cell wastes and the

exudates resulting from the irritation provoked. They may live in human skin for years,

periodically reproducing.

Mode of transmission

Direct transmission of the mites from a diseased to a healthy individual or , more infrequently ,

indirectly through clothing containing the mites or by sleeping in the same bed used by an

individual with scabies.


There is no actual penetration, but external parasitism, since the mites like on the surface, inside

the epidermis.

Main risk of infection

Poor communities, with little personal hygiene, in which soap is not used and people

share crowded sleeping accommodation.

Signs and symptoms

Incubation period: 3-30 days

Intense itching, especially at night, in different parts of the body: between the fingers of the

hands, at the wrists, bends of the elbow, breasts, chest, buttocks and waist, in breast feed children

also on the soles of the feet, ankles and palms of the hands.

Formation of small, pearly, white vesicles and short, thin, linear burrows/ visible under a lens,

lesion caused by scratching and the resulting skin infection.

Nodules and scalp involvement are seen mainly in infants.

Laboratory diagnosis

The localization of itching and the appearance of the lesions are in themselves characteristic.

Microscopic examination of skin scrapings can reveal the mites.

Treatment

* Hot bath followed by applications of a soapy emulsion of benzyl – benzoate 25% or

anti scabies ointment, to be repeated for 2 consecutive days

* At the same time, sterilize the clothing, towels and sheets by boiling and dried on heat

* Treat all the member of the family who have scabies.

*treat itch and secondary infection if necessary


PROPHYLAXIS

Individual

* Hygiene of the hand and skin

* Avoid contact with individual suspected of having scabies: Don’t sleep in their bed, clothing or

towels

Collective

Health education which primarily aims to teach the rules of personnel hygiene. The habitual use

of soap in cleaning the body and knowledge of the causative agent of scabies (mites) the life

cycle and modes of transmission.

ORAL CANDIDOSIS

Definition:

Oral candidiasis is fungus disease causing thrush (fungus diseases especially of children

affecting mouth and throat.

Candida infection include superficial mucosal infection, such as oropharyngeal (thrush,) glositis,

and otitis external

There is many species of Candida that can cause this disease but the primary agent is Candida

albicans

Signs: white plaque covering the mucosa when scraped, these plaques usually reveal an easily

hemorrhagic .It can cover all or part of oral mucosa; it can be a discrete lesion or cover all of the

oro pharyngeal mucosa.

Diagnosis

-Diagnosis of Candida infection is supported by potassium hydroxide preparation or gram stain

of lesions fluids.

Biopsy specimens or by culture on standard.


*The chronic oral Candida infection can occur in:

- Acquired immunodeficiency syndrome

- Nutritional deficiencies

- Head and neck radiation.

Complications

septicemia

Meningitis

Oesophageal candidosis

Digestive disorders

Treatment

-Nystatin

-In older children clotrimazole is recommended to keep the medication in contact with the lesion

longer.

-Daktarin gele of the mouth.

- The management concerns the: Complete diet, hygiene of the mouth, nasogastric tube.

V. NERVOUS SYSTEM (Meningitis, Convulsions, Encephalitis.)

A. CONVULSIONS

Definition:

Convulsions are violent motion of the limbs or body caused by involuntary contraction of

muscles.

Causes

Convulsions can be conditioned by

Fever: Febrile convulsion


Epilepsy

Breathing difficulty

Whooping cough

Brain inflammation

Meningitis

Encephalitis

Head injury

Brain tumor

Hypoglycemia

Drug over dose

Stroke

Certain types of poisoning

Alcohol withdrawal

Febrile convulsions: occur in young children when there is a rapid increase in their body

temperature. It affects up to 1 in 20 children between the ages of one and four but can affect

children between six months and about five years old.

Children who are at risk may naturally have a lower resistance to febrile convulsion than others.

Symptoms of Convulsions

The signs and symptoms mentioned in various sources for Convulsions includes the following:

Body twitching

Body spasms

Jerking limbs

Head spasms

Facial spasms

Bladder incontinence

Bowel incontinence

Loss of consciousness

Sleeping after convulsion

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Complications

Complications and sequelae of Convulsions include:

Acute confusional state

Incontinence

Gastric content aspiration

Involuntary muscular movements

Falls, injuries

Reduced level of consciousness

Treatment

Treatments depend on the type of seizure

First, give Anticonvulsant medications

Then, Treatment of the underlying cause

*Drugs and Medications used to treat Convulsions:

Phenytoin

Phenobarbital

Diazepan

MENINGITIS

Meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal

cord. It is usually caused by bacteria, viruses, or fungi but it can also be caused by certain

medications or illnesses.

Bacterial meningitis is rare, but is usually serious and can be life-threatening if it's not treated

right away. Viral meningitis (also called aseptic meningitis) is relatively common and far less

serious. It often remains undiagnosed because its symptoms can be similar to those of the

common flu.

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Kids of any age can get meningitis, but because it can be easily spread between people, living in

close quarters, teens, college students, and boarding-school students are at higher risk for

infection.

If dealt promptly, meningitis can be treated successfully. So it is important to get routine

vaccinations and know the signs of meningitis

Transmission

Most cases of meningitis (both viral and bacterial) result from infections that are contagious,

spread via tiny drops of fluid from the throat and nose of someone who is infected. The drops

may become airborne when the person coughs, laughs, talks, or sneezes. They then can infect

others when people breathe them in or touch the drops and then touch their own noses or mouths.

Sharing food, drinking glasses, eating utensils, tissues, or towels all can transmit infection as

well. Some infectious organisms can spread through a person's stool, and someone who comes in

contact with the stool such as a child in day care may contract the infection.

The infections most often spread between people who are in close contact, such as those who

live together or people who are exposed by kissing or sharing eating utensils.

Causes of Meningitis

Many of the bacteria and viruses that cause meningitis are fairly common and are typically

associated with other routine illnesses. Bacteria and viruses that infect the skin, urinary system,

gastrointestinal or respiratory tract can spread by the bloodstream to the meninges through

cerebrospinal fluid, the fluid that circulates in and around the spinal cord.

In some cases of bacterial meningitis, the bacteria spread to the meninges from a severe head

trauma or a severe local infection, such as a serious ear infection (otitis media) or nasal sinus

infection (sinusitis).

http://kidshealth.org/parent/infections/ear/otitis_media.html

http://kidshealth.org/parent/infections/lung/sinusitis.html


Many different types of bacteria can cause bacterial meningitis.

In infants, the most common causes are: Group B streptococcus, Escherichia coli, and Listeria

monocytogenes.

In older kids: Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis

(meningococcus) are more often the causes.

Another bacterium, Haemophilus influenza type b (Hib), can also cause the illness but because of

widespread childhood immunization, these cases are now rare.

Similarly, many different viruses can lead to viral meningitis, including enteroviruses (such as

coxsackievirus, poliovirus, and hepatitis A and the herpesvirus.

Cryptococcus neoformans can cause meningitis in immunocompromized individual i.e People

living with HIV

Symptoms of Meningitis

The symptoms of meningitis vary and depend both on the age of the child and on the cause of the

infection. Because the flu-like symptoms can be similar in both types of meningitis, particularly

in the early stages, and bacterial meningitis can be very serious, it's important to quickly

diagnose an infection.

The first symptoms of bacterial or viral meningitis can come on quickly or surface several days

after a child has had a cold and runny nose, diarrhea and vomiting, or other signs of an infection.

Common symptoms include:

fever

lethargy

irritability

headache


photophobia (eye sensitivity to light)

stiff neck

skin rashes

seizures

Infants with meningitis may not have those symptoms, and might simply be extremely irritable,

lethargic, or have a fever. They may be difficult to be comforted, even when they are picked up

and rocked.

Other symptoms of meningitis in infants can include:

jaundice (a yellowish tint to the skin)

stiffness of the body and neck (neck rigidity)

fever or lower-than-normal temperature

poor feeding

a weak suck

a high-pitched cry

bulging fontanel

Viral meningitis tends to cause flu-like symptoms, such as fever and runny nose, and may be so

mild that the illness goes undiagnosed. Most cases of viral meningitis resolve completely within

7 to 10 days, without any complications or need for treatment.

Diagnosis

Because bacterial meningitis can be so serious, if you suspect that your child has any form of

meningitis, it's important to do investigation to confirm or to exclude the illness.

The tests will likely include a lumbar puncture (spinal tap) to collect a sample of spinal fluid.

This test will show any signs of inflammation, and whether a virus or bacteria is causing the

infection.

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Treatment

*A child who has viral meningitis may be hospitalized, although some kids are allowed to

recover at home if they are not too ill. Treatment, including rest, fluids, and over-the-counter

pain medication, is given to relieve symptoms (e.g. paracetamol)

*If bacterial meningitis is diagnosed, or even suspected:

- start intravenous (IV) antibiotics as soon as possible ( e.g. cefotaxim, ceftriaxon, Ampicilline+

gentamycine)

- Fluids may be given to replace those lost to fever, sweating, and vomiting,

- corticosteroids may help reduce inflammation of the meninges, depending on the cause of the

disease. (e.g. head trauma)

- anticonvulsants might be given for seizures.

- Some kids may need supplemental oxygen or mechanical ventilation if they have difficulty

breathing.

Complications & prognosis

hearing loss,

visual impairment,

seizures, and

learning disabilities (mental retardation)

The heart, kidneys, and adrenal glands also may be affected.

Although some kids develop long-lasting neurological problems, most who receive

prompt diagnosis and treatment recover fully.

Prevention

* Routine immunization: the vaccines against Hib, measles, mumps, polio, meningococcus, and

pneumococcus can protect against meningitis caused by these microorganisms.

http://kidshealth.org/parent/growth/medical/immunization_chart.html


* In certain countries, the 11 years old get vaccinated for meningococcal disease, a serious

bacterial infection that can lead to meningitis. The Children who have not had the vaccine and

are over 11 years old should also be immunized, particularly if they're going to college, boarding

school, camp, or other settings where they are going to be living in close quarters with others.

This vaccine may also be recommended for people who are travelling to countries where

meningitis is more common.

* Good hygiene is an important way to prevent any infection: encourage kids to wash their hands

thoroughly and often, particularly before eating and after using the toilet.

* Avoiding close contact with someone who is obviously ill and not sharing food, drinks, or

eating utensils can help stop the spread of germs as well.

* In certain cases, may decide to give antibiotics to anyone who has been in close contact with

the person who is ill to help prevent additional cases of illness.

ENCEPHALITIS

Encephalitis literally means an inflammation of the brain, but it usually refers to brain

inflammation caused by a virus. It's a rare disease that occurs in approximately 0.5 per 100,000

individuals most commonly in children, the elderly, and people with weakened immune systems

(i.e., those with HIV/AIDS or cancer).

Although several thousand cases of encephalitis (also called acute viral encephalitis or aseptic

encephalitis) are reported to the Centers for Disease Control and Prevention (CDC) every year,

experts suspect that many more may go unreported because the symptoms are so mild.

Signs and Symptoms

* Symptoms in milder cases of encephalitis usually include:

fever

headache


poor appetite

loss of energy

a general sick feeling

* In more severe cases of encephalitis, the symptoms include:

High fever

severe headache

nausea and vomiting

stiff neck

confusion

disorientation

personality changes

convulsions (seizures)

problems with speech or hearing

hallucinations

memory loss

Difficulty in walking

drowsiness (lethargy)

coma

It's harder to detect some of these symptoms in infants, but important signs to look for include:

Vomiting

a full or bulging fontanel

crying that doesn't stop or that seems worse when an infant is picked up or handled in some

way

body stiffness

Causes

Because encephalitis can be caused by many types of germs, the infection can be spread in

several different ways.


- One of the most dangerous and most common causes of encephalitis is the herpes simplex

virus (HSV). HSV is the same virus that causes cold sores around the mouth, but when it attacks

the brain it may occasionally be fatal. Fortunately, HSV encephalitis is very rare.

- Encephalitis can be a very rare complication of Lyme disease transmitted by ticks, or of rabies

spread by rabid animals.

- Milder forms of encephalitis can follow or accompany common childhood illnesses, including

measles, mumps, chickenpox, rubella, and mononucleosis. Viruses like chickenpox spread

mostly via the fluids of the nose and throat, usually during a cough or sneeze.

- Less commonly, encephalitis can result from a bacterial infection, such as bacterial meningitis,

or it may be a complication of other infectious diseases like syphilis.

- Certain parasites, like toxoplasmosis, can also cause encephalitis in people with weakened

immune systems.

Prevention

- Encephalitis cannot be prevented except to try to prevent the illnesses that may lead to it.

- Encephalitis that may be seen with common childhood illnesses can be largely prevented

through proper immunization.

- Kids should also avoid contact with anyone who already has encephalitis.

Diagnosis

- Imaging tests, such as computed tomography (CT) scans or magnetic resonance imaging

(MRI), to check the brain for swelling, bleeding, or other abnormalities

- Electroencephalogram (EEG), which records the electrical signals in the brain, to check for

abnormal brain waves

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- Blood tests to confirm the presence of bacteria or viruses in the blood, and whether a person is

producing antibodies (specific proteins that fight infection) in response to a germ

- Lumbar puncture, in which cerebrospinal fluid is checked for signs of infection

Treatment

Hospitalization

Monitor the blood pressure, heart rate, and breathing,

Monitor body fluids, to prevent further swelling of the brain.

Antiviral drugs can be used to treat some forms of encephalitis, especially the type

caused by the herpes simplex virus.

Corticosteroids may also be used in some cases to reduce brain swelling.

If a child is having seizures, anticonvulsants may also be given.

Over-the-counter (OTC) medications, like acetaminophen (Paracetamol), can be used to

treat fever and headaches.

Evolution & complications: For most forms of encephalitis, the acute phase of the illness (when

symptoms are the most severe) usually lasts up to a week. Full recovery can take much longer,

often several weeks or months. Most people with encephalitis make a full recovery.

In a small percentage of cases, some complications may occur, including:

- learning disabilities,

- speech problems,

- memory loss, or

- lack of muscle control.

- Rarely, if the brain damage is severe, encephalitis can lead to death. Infants younger than 1 year

are at greatest risk of death from encephalitis.

VI. ENDOCRIN SYSTEM

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DIABETES MELLITUS

Diabetes mellitus (DM) or simply diabetes is a chronic health condition in which the body either

fails to produce sufficient amount of insulin (reduced insulin secretion) or responds abnormally

to insulin (decreased glucose utilization). The ultimate outcome for all the types of diabetes is

high blood glucose level or hyperglycemia.

TYPES OF DIABETES MELLITUS

1. Type 1 diabetes: insulin deficiency

2. Type 2 diabetes: insulin resistance

3. Gestational Diabetes Mellitus (GDM)

Type 1 diabetes

Etiology

- Genetic factor

-Immune-mediated = cell destruction, usually leading to absolute insulin deficiency

-Idiopathic

- Pancreatitis with destruction of islet cells

- Some viruses such as rubella, mumps, coxsackie, cytomegalovirus are related to the destruction

of beta cells.

Pathophysiology

Type 1 diabete result from a severe, absolute lack of insulin caused by loss of beta cells.

Destruction of islet cells is related to genetic susceptibility and autoimmunity. There are islet cell

autoantibodies that participate in damage of islet cells. When 80% to 90% of the insulin-

secreting beta cells of the islet of Langerhans are destroyed, then the hyperglycemia and other

symptoms occur.

The pathophysiology of diabetes mellitus (all types) is related to the hormone insulin, which is

secreted by the beta cells of the pancreas. This hormone is responsible for maintaining glucose

level in the blood. It allows the body cells to use glucose as a main energy source. However, in a

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diabetic person, due to abnormal insulin metabolism, the body cells and tissues do not make use

of glucose from the blood, resulting in an elevated level of blood glucose or hyperglycemia.

Over a period of time, high glucose level in the bloodstream can lead to severe complications,

such as eye disorders, cardiovascular diseases, kidney damage and nerve problems.

Manifestations

Polydipsia

Polyuria

Polyphagia

Weight loss: the glucose is not used by cells because there is lack of insulin, so, fats and

proteins are used as source of energy.

Fatigue

Type 2 Diabetes mellitus

Etiology & risk factors

- Obesity is the most powerful risk factor

- Familiar

- MODY (Maturity Onset of Diabetes of Youth), a subset of type 2 diabetes is

thought to be autosomal because it affects 50% of first-degree relatives

Pathophysiology

Cellular resistance is a factor for 60 - 80% of individuals with type 2 diabetes. Insulin resistance

is increased with obesity. The release of free fatty acids from adipocytes blocks insulin receptors.

A decreased number of insulin receptors is responsible for insulin resistance followed by

hyperinsulinemia which occurs often in early stages of type2 diabetes. This hyperinsulinemia is a

compensatory adaptation to insulin resistance in tissues induced by obesity until pancreas can not

continue to overproduce insulin. Since the body cells and tissues are non responsive to insulin,

glucose remains in the bloodstream resulting in hyperglycemia.

Manifestations

- Classic symptoms: polydipsia, polyphagia (unexplained weight loss), polyuria

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- monilial infection with pruritis especially in girls

Diagnosis

2 hour stimulated Glycemia > 200mg/dl

Fasting plasma glucose > 126mg/dl

Urine analysis: Glucosuria, ketonuria

Treatment

- Insuline in case of type 1 diabetes, and in late stage of type 2 diabetes

- Oral hypoglycemiant agents in type 2 diabetes in early stages

- Dietetic measures

- Monitor glycemia before meal and before bedtime

Complications

Acute complications

- Diabetic ketoacidosis: with hyperglycemia and ketonuria manifested by acetone smelling

(fruity odor)

- Hyperosmolar coma: with hyperglycemia(> 600mg/dl) and dehydration

- Hypoglycemia

Chronic complications

- Hypertension

- Prolonged wound healing

- Infection

- Neuropathy

- Nephropathy

EDUCATION

- Education about signs and symptoms of hypoglycemia

- During any journey, the patient should carry the drugs on him/her. The diabetic card is also

necessary, and the patient should not forget to carry some foods or fluid containing sugar to take

in case of hypoglycemia

- Education on self injection: number of injections per day, way of administration (S/C route)

and site of injection


- General hygiene specifically feet hygiene

- Educate the patient and the family the importance of insulin therapy and some complications

of diabetes if insulin is not taken carefully

- Don’t forget the importance of diabetic regimen

- Advise the patient/parents to be in diabetic association (it will help her or him to have

medication on low cost, and he/she will learn more about the diabetic mellitus)

CHAPTER II. NUTRITIONAL DEFICIENCIES

2.1 PROTEIN- ENERGY MALNUTRITION

Protein deficiency: KWASHIORKOR

Caloric deficiency: MARASMUS

Mixed form: PROTEIN-ENERGY MALNUTRITION

Malnutrition is directly responsible for 300,000 deaths per year in children younger than 5 years

in developing countries and contributes indirectly to over half the deaths in childhood

worldwide.

KWASHIORKOR


It is a severe deficiency of protein. This type of malnutrition in children often occurs after the

children weaned between age of 18 and 48 months. It is caused by deficiency in protein, and is

characterized by edema.

Causes & Risk factors

Inadequate protein intake/ protein deficiency

Poverty: lack of food

Ignorance: about food preparation i.e. balanced food

Weaning: early weaning associated with poverty, late weaning also predispose to

kwashiorkor

Short interval between birth: the first child will be neglected and may get kwashiorkor

Low birth weight, Poor growth in the first few months.

Twins

Diarrhoea in case of mal absorption

Culture: taboos

MARASMUS

Marasmus is a state of starvation due to calories deficiency, in which almost all muscle fat is

used, characterized by reduced muscle skinfold, the appearance of necked bone and the child that

is look like a worried old man.

Causes & risk factors

Inadequate food intake / Deficiency in nutritional composition: with low calories

Caloric deficiency secondary to acute diseases especially diarrhoea.

Malabsorption: e.g.: Lactose intolerance

Child abuse: child neglect with lack of food: hunger

Low socio-economic factors: poverty, ignorance, culture (taboos)

Comparison of Marasmus and Kwashiorkor

Elements of comparison Marasmus Kwashiorkor


P.E.M

Protein-energy malnutrition also called proteino-caloric malnutrition is a mixed form of

marasmus and kwashiorkor. The predominant signs and symptoms indicate which form to

manage.

Causes & risk factors

- inadequate intake of calories and proteins

- bottle feeding: milk that is very diluted (much water)

- inadequate knowledge of proper child care: child neglect

- generally lack of the food: poverty, famine

cause Energy intake deficiency Protein intake deficiency

Clinical features Starved appearance (thin) Well-nourished appearance

Weigh loss > 10% Easy hair plackability

Subcutaneous fat is minimal:

triceps skinfold < 3mm

Edema: forearm, legs

mid upper-arm

circumference(MUAC) <

125mm (infants ≥ 6months)

Weak and looks like hungry:

appetite, crying is weak

No appetite, apathetic child,

crying for along time

Laboratory findings Serum Albumin level < 2.8

g/dl

Diagnostic criteria Triceps skinfold < 3mm

Mid- upper-arm circumference

< 125mm

-Serum albumin level < 2.8

g/dl

At least one of the following:

-Edema of 2 legs

-Easy hair plackability

-Poor wound healing, skin

breakdown, decubitus ulcers


- improper absorption

- socio-cultural factors: ignorance, taboos

Anthropometric measures

weight

height

mid- upper-arm circumference (MUAC)

Skinfold thickness

Using Z- score, check weight for age, weight for height, and height for age Z- score according to

sex. a Z-score with a standard deviation ≤ -2 is considered abnormal. Thus an abnormal Z- score

or abnormal MUAC explains one or another form of malnutrition (severe or moderate, acute or

chronic).

Other tests

- Blood tests: serum albumin level, CBC

- Stool examination

MANAGEMENT

Prevention

Immunization

Adequate breast feeding: exclusive breastfeeding up to 6 months, then introduce other

fluids, food, and continue to breastfeed up to 2 years.

Weaning process should be started on time (6 months)

Prompt treatment of any illness is important

Parental education on prevention: behaviour and/ belief change

Encourage the family and the community on home gardens and the use of the available

food to prevent malnutrition

Advice on both environmental and personal hygiene to prevent repetitive diarrhea that

can be a factor of malnutrition

Help the community to know the source of carbohydrates such as rice, vegetable,

cassava, wheat, Irish potatoes, cereals, grains, sweet potatoes, sugar, honey,… and the

source of proteins such as eggs, meat, fish, beans, soy beans, peas, milk…


Surveillance of the child’s weight, height, MUAC through monthly follow-up of the

children under 5 years, in order to detect early the symptoms of malnutrition, and act

accordingly.

Treatment

dietary intervention in collaboration with a dietitian or other nutritional professionals

- Providing diet with high quality of protein, carbohydrate, vitamins and minerals

- Increase the number of meals per day

- Give therapeutic milk (see course of dietetics and nutrition)

Treat the underlying cause

Treat the symptoms

Nasogastric tube in case of vomiting

Regular weighing of children to assess the evolution (Children with edema must be

assessed carefully for actual nutritional status because edema may mask the severity of

malnutrition).

In case of kwashiorkor, check serum albumin level

CHAPTER III. PREVENTION OF MOTHER TO CHILD TRANSMISSION/ CARE FOR

HIV- INFECTED CHIDREN

An estimated 3.4 million children were living with HIV at the end of 2011, 91% of them in sub-

Saharan Africa. Most of these children acquire HIV from their HIV-infected mothers during

pregnancy, birth or breastfeeding (WHO, 2012)

The mother to child transmission of HIV may be :

In utero: 5-8 %

Perinatal: 10-20%


Postnatal: 14-20%

Total: 30-40% without PMTCT

Risk factors of mother to child transmission

Advanced state of the infection for the mother (increased viral load)

primo infection

CD4 less than 500/µl

Obstetrical factors

Prolonged labour with membranes ruptured

premature rupture of membranes

episiotomy

Use of forceps and vaccum extractor (ventouse)

Prematurity of the baby

Twin pregnancy

Dystocic birth

*Breast Feeding mixed with artificial feeding is of high percentage

So either exclusive artificial feeding should be adopted, if not possible especially in developing

country, breastfeeding up to 18 months to minimize mortality due to malnutrition in infants

(exposed children are on ARVs for 6 weeks and Cotrimoxazole when the child is still negative).

Breastfeeding is also protected by mother’s ARVs.

Strategies of prevention

primary prevention by IEC on the spread of sexual transmitted infections and voluntary

HIV testing

prevention of unwanted pregnancies by using family planning methods for those who are

infected

prevention of in uterus transmission by giving Antiretrovirals : Tritherapy

(TDF+3TC+EFV) for pregnant mothers at the beginning of the 2nd

trimester of pregnancy

(14week of pregnancy)


safe methods of birth and breastfeeding: e.g Tritherapy for the mother when starting

labour, and Niverapine for the infant within 6-12 hours and continue up to 6 weeks (see

the new PMTCT protocol 2011,). Minimize the risk for infection by promoting C- section

especially for those with STIs and vaginal ulcerations, minimizing vaginal examination,

episiotomy and avoiding amniocentesis.

Breastfeeding avoidance may be helpful for the mothers who have other source of

nutrients. If breastfeeding is adopted, exclusive breastfeeding in 6 months, then introduce

appropriate food and continue breastfeeding for 12 months.

ANTIRETROVIRAL DRUGS FOR TREATING PREGNANT WOMEN

AND PREVENTING HIV INFECTION IN INFANTS (2010 WHO recommendations)

Antiretroviral treatment options recommended for HIV-infected pregnant

women who are eligible for treatment

Eligibility criteria

- CD4 ≤ 350/mm3 regardless on clinical stages

- clinical stages 3 or 4 regardless on CD4 cell count

Maternal ART + infant ARV prophylaxisher

Maternal antepartum daily ART, starting as soon as possible irrespective of gestational age, and

continued during pregnancy, delivery and thereafter. Recommended regimens include:

AZT + 3TC + NVP or

AZT + 3TC + EFV* or

TDF + 3TC + NVP or

TDF + 3TC + EFV*

Infant

Infant: Daily NVP or twice-daily AZT from birth until 4 to 6 weeks of age (irrespective of the

mode of infant feeding).

Two options are recommended for HIV-infected pregnant women who are not eligible for

ART: option A is maternal AZT + infant ARV prophylaxis; option B is maternal triple ARV

prophylaxis.

Option A: maternal AZT + infant ARV prophylaxis

- antepartum twice-daily AZT, plus sd-NVP at the onset of labour , plus twice daily

AZT + 3TC during labour and delivery and continued for 7 days postpartum.

- In breastfeeding infants, daily administration of NVP to the infant from birth until 1

week after all exposure to breast milk has ended, or for 4 to 6 weeks if breastfeeding


stops before 6 weeks (but at least 1 week after the early cessation of breastfeeding), is

recommended.

- In infants receiving only replacement feeding, daily administration of NVP from birth

or sd-NVP at birth plus twice-daily AZT from birth until 4 to 6 weeks of age is

recommended.

Option B: maternal triple ARV prophylaxis

- antepartum daily triple ARV prophylaxis until delivery, or,

- if breastfeeding, until 1 week after all exposure to breast milk has ended.

Recommended regimens include

AZT + 3TC+ LPV/r,

AZT + 3TC + ABC,

AZT + 3TC + EFV, or

TDF + 3TC + EFV.

In infants, regardless of infant feeding practices (breastfeeding or replacement feeding),

the maternal triple ARV prophylaxis should be combined with the daily administration of

NVP or twice-daily AZT to the infant from birth until 4 to 6 weeks

Palliative care

Palliative care are all care that improve the quality of life for patients and families facing the

problems associated with life-threatening illness by preventing and relieving sufferings through

the early identification, assessment and treatment of pain and other physical, psychosocial and

spiritual problems ( WHO, 2003)

Goal of palliative care

The goal of palliative care is to provide support and care that makes life comfortable for patients

throughout all phases of the disease, so they can leave as fully and comfortably as possible.

Types of palliative care

The following 4 categories of essential palliative care are: clinical care, psychological care,

social care, and spiritual care.

a) Clinical care:

providing ART drugs to the patient,


prophylaxis for opportunistic infections ( co-trimoxazole),

treatment and care for opportunistic infections,

nutritional support for ART adherence.

WHO Classification of HIV infection: Staging

STAGES CHARACTERISTICS

Stage I

Primo-infection

Stage II

Asymptomatic (latent phase)

Stage III

Symptomatic (Prolonged diarrhea, fever >1

months, lymph nodes swelling, herpes

zoster…)

Stage IV

Opportunistic diseases

Paediatric classification of HIV infection stages according to CDC (Centre for diseases

control): immunologic evaluation

Stages 0-11 months 1-5 years 6-12 years

No immunity

deficiency

CD4 ≥1500 / µl CD4 ≥1000 / µl CD4 ≥500 / µl

Moderate deficiency CD4 750-1499 / µl CD4 500-999 / µl CD4 200-499 / µl

Severe deficiency CD4 <750 / µl CD4 <500 / µl CD4 <200 / µl


Proposed CD4 thresholds for initiation of ART in infants and children; WHO stages

>18 months with WHO stage 3 and 4: Treat all

Criteria

< 18 months

18-35

months

36-60 months

> 5years

CD4/µl

Treat all

<1000

<750

<350

Note: The new national protocol (2011) proposes that all children under 5 years of age who are

HIV positive are treated with ARVs regardless of their CD4 cell count or clinical stage. (for

details, see new PMTCT protocol 2011)

ART regimen in children

1st and 2

nd line regimen in non-exposed to sd NVP (PMTCT exposure)

Recommended 1st line regimen Recommended 2

nd line regimen

ABC+3TC+EFV/NVP

AZT+3TC+LPV/RTV

Alternative 1st line regimen Alternative 2

nd regimen


AZT+3TC+EFV/NVP

ABC+3TC+LPV/RTV

1st and 2nd

line regimen in exposed to sd NVP

Recommended 1st line Recommended 2

nd line

ABC+ 3TC+ LPV/RTV AZT+ 3TC+ LPV/RTV

Alternative Alternative

AZT+ 3TC+ LPV/RTV ABC+ 3TC+ LPV/RTV

Protease inhibitors in 1st line treatment of children

*Use LPV/RTV in 1st line therapy if:

Mother ever failed NVP, or

Mother or infant got NVP for PMTCT, or

Mother took NVP while breastfeeding, or

Child ever failed NVP,or

Intolerance or other contraindication to NNRTI

b) Psychological care:

assess the child for psychological problems and give support through counseling (

counseling of the family, counseling of the child, group support)

Treatment of HIV related psychiatric illness, such as depression. Some tools to

screen children’s depression are available such as Maria Kovacs’ children’s

depression inventory.

c) Social care:

stigma prevention


Advocate for school adherence: some NGOs help HIV- infected children in

school affairs, by paying school fees, providing school materials…

d) Spiritual care: counseling related to hopes and forgiveness


CHAPTER IV. INFANTILE SURGERY

1. PHIMOSIS & PARAPHIMOSIS

Phimosis and paraphimosis are both disorders in which the foreskin (prepuce) is “too tight” to

move easily over the glans penis.

Phimosis is a condition in which the foreskin cannot be retracted back over the glans, whereas

paraphimosis is the opposite: the foreskin is retracted and cannot be moved forward to cover the

glans.

a) Phimosis

The inability to retract the foreskin is normal in infancy and is caused by congenital adhesions.

During the 1st three years of life, congenital adhesions (between the foreskin and the glans)

separate naturally with penile erections and are not an indication for circumcision.

Phimosis can occur at any age and is most commonly caused by poor hygiene and chronic

infection (e.g balanitis).

Reasons for seeking treatment include: edema, redness, tenderness of the prepuce and purulent

discharge; inability to retract the foreskin is a less common complain.

Circumcision, if needed, is performed after infection has been eradicated by antibiotics.

Complications:- Inflammation of the glans (balanitis)

- Inflammation of the prepuce (posthitis)

- Paraphimosis

b) Paraphimosis

The retracted foreskin can constrict the penis, causing edema of the glans.

Causes: it may happen after rigorous cleaning, catheter insertion

Treatment: If the foreskin cannot be reduced manually, surgery (circumcision) must be

performed to prevent necrosis of the glans caused by constricted blood vessels.


Complication: Necrosis of the glans.

2. CRYPTORCHIDISM

The cryptorchidism is a condition whereby one or both testes fail to descend into the scrotum. It

is the most common congenital condition involving the testes.

About 3% to 6% of all full-term males and 20% to 30% of all premature males have

undescended testes at birth.

The testes may remain in the abdomen, or descent may be arrested in the inguinal canal

or the puboscrotal junction.

In approximately 75% to 90% of infants with cryptorchidism, the testes descend into the

scrotum by 1 year of age.

Causes

- Developmental delay

- Defect of the testis

- Deficient maternal gonadotropin stimulation

- Some mechanical factor that prevents descent through the inguinal canal such as*short

spermatic cord, *fibrous bands or adhesions in the normal path of the testes, * or

narrowed inguinal canal.

Cryptorchidism does not prevent puberty or maintenance of secondary sex characteristics if the

testis is otherwise normal.

Complications

- Infertility if untreated

- Neoplastic processes: the undescended testes are susceptible to cancer with the risk of 35

to 50 times greater for men with cryptorchidism or a history of cryptorchidism than for

the general male population.

Physical examination

Palpation of the scrotum: Absence of one or both testes in the scrotum


Diagnosis

Ultrasonography or a CT scan can help clinicians locate a non palpable testis that has

migrated intra-abdominally.

Treatment

- The treatment often begins with hormonal therapy.

- If hormonal therapy is not successful, to preserve fertility, surgical correction

(ORCHIOPEXY) of cryptorchidism is attempted when the child is about 2 years of

age. Orchiopexy is recommended no later than age 5 or 6 years.

- Placement of the cryptorchid testes into the scrotal sac does not decrease the potential

for malignancy, but it does facilitate the examination and tumor detection.

3. TORSION OF THE TESTIS

The torsion of the testis is the rotation of the spermatic cord on its vascular pedicle, interrupting

its blood supply.

Torsion of the testis is the one of several conditions that causes an acute scrotum (testicular pain,

and swelling).

It is responsible for 16% to 42% of cases of boys with acute scrotum.

The torsion can occur at any age, but is most common among children and adolescents,

particularly at puberty.

Clinic

The onset of torsion may be spontaneous or follow physical exertion or trauma.

Torsion twists (make a helix) the arteries and veins in the spermatic cord, reducing or

stopping circulation to the testis.

Vascular engorgement and ischemia develop, causing acute scrotal swelling and severe

pain not relieved by rest or scrotal support

Treatment

Torsion of the testis is a surgical emergency


If it cannot be reduced manually (scrotal elevation), surgery must be performed within 6

hours after the onset of symptoms to preserve normal testicular function.

ORCHIOPEXY: spermatic cord is untwisted and testicle is sutured to scrotum.

4. HYPOSPADIAS Definition: A condition where the urethral orifice opens in abnormal position on the ventral

surface of the penis or scrotum.

Causes /risk factors

- Use of maternal estrogen or progesterone during pregnancy

- Hereditary

Signs and symptoms

- Difficulty directing the urinary stream and stream spraying

- Chordee

- Males with this condition often have a downward curve (ventral curvature or chordee) of the

penis during an erection

- Abnormal spraying of urine

- Having to sit down to urinate

- Malformed foreskin that makes the penis look “hooded”

Investigations

- A physical examination can diagnose this condition

- A buccal smear and karyotyping

- Urethroscopy

- cystoscopy

- Excretory urography

Complications

- Difficulty with toilet training

- Problems with sexual intercourse in adulthood

- Urethral strictures and fistulas may form throughout the boy’s life

Management

- Infants with hypospadias should not be circumcised

- For a Minor degree of hypospadias (e.g. glandular hypospadias) require no treatment

Surgical management: During the surgery, the penis is straightened and the hypospadias is

corrected using tissue grafts from the foreskin. The repair may require multiple surgeries


• Relief of the chordee

• Urethral reconstruction

• In some cases, more surgery is needed to correct fistulas or a return of the abnormal penis

curve

- Surgery is usually done before the child starts school

- Surgery can be done as young as 4 months old, better before the child is 18 months old

5. HERNIAS

a) INGUINAL HERNIA

An inguinal hernia is a condition in which intra-abdominal fat or part of the small

intestine, also called the small bowel, lumps or bulges through a weak area in the lower

abdominal muscles called inguinal canal.

An inguinal hernia can occur any time from infancy to adulthood and is much more

common in males than females. It is the 2nd

hernia in childhood, after umbilical hernia.

TYPES

Indirect inguinal hernias

Indirect inguinal hernias are congenital hernias and are much more common in males than

females because of the way males develop in the womb.

In a male fetus, the spermatic cord and both testicles starting from an intra-abdominal location

normally descend through the inguinal canal into the scrotum. Sometimes the entrance of the

inguinal canal at the inguinal ring does not close as it should just after birth, leaving a fault in the

abdominal wall. Fat or part of the small intestine slides through the weakness into the inguinal

canal, causing a hernia. In females, an indirect inguinal hernia is caused by the female organs or

the small intestine sliding into the groin through a weakness in the abdominal wall.

Premature infants are especially at risk for indirect inguinal hernias because there is less time for

the inguinal canal to close.

Direct inguinal hernias

Direct inguinal hernia are acquired hernia, and are less common in infants and children.


A direct hernia develops gradually because of continuous pressure on the muscles. One or more

of the following factors can cause pressure on the abdominal muscles and may worsen the

hernia:

lifting heavy objects

straining on the toilet because of constipation

weight gain

chronic coughing

Indirect and direct inguinal hernias usually slide back and forth spontaneously through the

inguinal canal and can often be moved back into the abdomen with gentle massage.

Symptoms

a bulge (swelling) in the groin,

discomfort or sharp pain,

a feeling of pressure in the groin,

a burning, or aching feeling at the bulge.

Complications

Incarceration: Incarcerated inguinal hernia is a hernia that becomes stuck in the groin

or scrotum and cannot be massaged back into the abdomen.

Strangulation: a strangulated hernia, in which the blood supply to the incarcerated small

intestine is limited, is a serious condition and requires immediate medical attention.

Symptoms of strangulation include:- extreme tenderness and redness in the area of the bulge,

- sudden pain that worsens quickly,

- fever and rapid heart rate,

- nausea, and vomiting.

Diagnosis

Inguinal hernia is diagnosed through physical examination

Treatment


Surgery: herniorraphy

b) UMBILICAL HERNIA

Definition: It is a bulge in the navel due to intestine, fat, or fluid that pushes through a hole in

the baby’s abdomen muscles (umbilical ring that is not closed just before birth).

Cause

The ring of muscle and other tissue that forms where blood vessels in the umbilical cord enter a

fetus's body is known as the umbilical ring. This ring usually closes before the baby is born. If it

does not close, tissue may bulge through the opening, creating an umbilical hernia.

Clinical manifestations

An umbilical hernia is usually seen after the umbilical cord stump falls off, within a few weeks

after birth. But some children don’t get a hernia until they are infants or toddlers.

Symptoms may include: - A soft bulge under the skin of your child’s belly button (navel)

- The part of the bulge can be pushed back in

- The bulge may be easier to see when your child sits or stands upright

or when a child is crying, coughing, or having a bowel movement.

- Most children don't feel pain from the hernia.

- The child may experience vomiting and signs of infection such as

redness and swelling on the belly button associated with fever.

Diagnosis

Umbilical hernia is diagnosed through physical examination.

Treatment

http://www.webmd.com/hw-popup/intestine-bowel

http://www.webmd.com/heart/anatomy-picture-of-blood

http://children.webmd.com/tc/growth-and-development-ages-12-to-24-months-overview

http://www.webmd.com/skin-problems-and-treatments/picture-of-the-skin


Umbilical hernias usually close on their own before a baby is 1 year old. If a hernia has not

closed by the time your child is 5 years old, your child probably will need surgery to close it.

The child may have surgery before he or she is age 5 if:

The hernia is large and has not closed by age 2.

There is another problem, such as an infection.

The way the hernia looks worries you or your child.


CHAPTER V. PEDIATRIC EMERGENCIES: HOME ACCIDENTS

I. BITES & STING

1. SNAKEBITES

Epidemiology

Venomous snakes bite rates are highest in temperate and tropical regions where the population

subsists by manual agriculture. Estimates indicate >5 million bites annually by venomous snakes

worldwide, with >125,000 deaths.

Clinical Manifestations

- Local swelling

- Pain (myalgia)

- Ecchymosis

- local tissue necrosis caused by proteolytic enzymes of the venom

- Myocardial depressant factors of the venom reduce cardiac output, and

- Neurotoxins of the venom inhibit peripheral nerve impulses and can cause ptoses, altered

mental status

- Severe poisoning may result in paralysis, including the muscles of respiration, and lead to

death due to respiratory failure and aspiration.

- Hemorragins molecular of the venom promote vascular leakage and cause both local and

systemic bleeding including hemorrhagic bullae and serum-filled vesicles.

Treatment

Field Management

- Reassure the patient

- Immobilize the extremity

- Get to the hospital

- Inform the physician to telltale the signs and symptoms


Hospital Management

- Any patient with signs of venom poisoning should be observed in the hospital for at least

24 h.

- Unstable patients should be admitted to a monitored setting.

- The victim should be closely monitored (vital signs, cardiac rhythm, oxygen saturation,

urine output) while a history is quickly obtained and a rapid, systematic physical

examination is performed.

- Victims should be watched carefully for evidence of difficulty swallowing or respiratory

insufficiency, which should prompt definitive securing of the airway by endotracheal

intubation.

- The level of swelling in a bitten extremity should be marked and limb circumferences

measured in several locations every 15 min until swelling has stabilized.

- Large-bore IV access in unaffected extremities should be established.

- Fluid resuscitation with Normal saline should be initiated for clinical shock.

- The key to management of venomous snakebite is the administration of specific

antivenom. Circulating venom components bind quickly with heterologous antibodies

produced in animals immunized with the venom in question (or a very closely related

venom). Antivenoms may be monospecific (for a particular snake species) or polyspecific

(covering several medically important species in the region)

. Example of antivenom: crotalidae polyvalent immune fab

- Indications for antivenom administration in victims of viperid bites include any evidence

of systemic envenomation (systemic symptoms or signs; laboratory abnormalities) and

(possibly) significant, progressive local findings (e.g., soft tissue swelling crossing a joint

or involving more than half the bitten limb in the absence of a tourniquet).

- For viperid bites, antivenom administration should generally be continued as needed until

the victim shows definite improvement (e.g., stabilized vital signs, reduced pain, restored

coagulation).

- Neurotoxicity from elapid bites may be harder to reverse with antivenom. Once

neurotoxicity is established and endotracheal intubation is required, further doses of


antivenom are unlikely to be beneficial. In such cases, the victim must be maintained on

mechanical ventilation until recovery occurs, which may take days to weeks.

- In many developing countries, antivenom resources are inadequate, contributing to high

morbidity and mortality rates in these regions. The rates of acute anaphylactoid reactions

to some of these products exceed 50%. If the risk of allergic reaction is significant,

pretreatment with appropriate loading doses of IV antihistamines (e.g., diphenhydramine,

1 mg/kg to a maximum of 100 mg; and cimetidine, 5–10 mg/kg to a maximum of 300

mg) may be considered. In some regions, a prophylactic SC or IM dose of epinephrine is

given in an effort to reduce the risk of reaction.

- Care of the bite wound includes application of a dry sterile dressing and

splinting/immobilization of the extremity with padding between the digits.

- Once the administration of an indicated antivenom has been initiated, the extremity

should be elevated above heart level to relieve edema.

- Tetanus immunization should be updated as appropriate.

- Antibiotics can be considered, however, if misguided first-aid efforts have included

incisions or mouth suction. Give cefalosporine: e.g. Ceftriaxone.

- A dose of IV mannitol (1 g/kg) can be given in an effort to reduce muscle edema if the

patient's hemodynamic status is stable.

- Wound care in the days after the bite may require careful aseptic debridement of clearly

necrotic tissue once coagulation has been restored. Intact serum-filled vesicles or

hemorrhagic blebs should be left undisturbed. If ruptured, they should be debrided with

sterile technique.

- Outpatient analgesic treatment should be continued.

- In the event of serum sickness (fever, chills, urticaria, myalgias, arthralgias, and possibly

renal or neurologic dysfunction developing 1–2 weeks after antivenom administration),

the victim should be treated with systemic glucocorticoids (e.g., oral prednisone, 1–2

mg/kg daily) until all findings resolve, at which point the dose is tapered over 1–2 weeks.

Oral antihistamines (e.g., diphenhydramine in standard doses) provide additional relief of

symptoms.

2. BEE STING


Honeybees often lose their stinging apparatus and the attached venom sac in the act of stinging

and subsequently die.

Manifestations

*Uncomplicated stings cause:


- immediate pain,

- a wheal-and-flare reaction,

- local edema and swelling that subside in a few hours.

*Stings from accidentally swallowed insects may induce life-threatening edema of the upper

airways.

*Multiple stings can lead to:

- vomiting,

- diarrhea,

- generalized edema,

- dyspnea,

- hypotension, and collapse.

- intravascular hemolysis may cause renal failure.

- Death from the direct effects of venom has followed 300–500 honeybee stings.

Treatment

- Stingers from honeybees embedded in the skin should be removed as promptly as

possible, using any method available, to limit the quantity of venom delivered.

- The site should be cleansed and disinfected and ice packs applied to slow the spread of

venom.

- Elevate the affected site

- Administration of analgesics and oral antihistamines relieve symptoms.

- Give the steroids ( e.g. Oral prednisolone) in case of large local reactions.

- Patients with numerous stings should be monitored for 24 h for evidence of renal failure

or coagulopathy.

- In case of anaphylaxis:

. Give Epinephrine

. A tourniquet may slow the spread of venom.

. Give parenteral antihistamines,

. fluid resuscitation,


. bronchodilators,

. oxygen and intubation.

.Patients should be observed for 24 h for recurrent anaphylaxis.

II. INGESTION OF CHEMALS

1. INGESTION OF HYDROCARBONS

Hydrocarbon is the one of the most toxic exposures, usually occurring in children younger than 5

years old. Hydrocarbons are commonly used as fuel, polishes,…

Ingested hydrocarbons generally produce little systemic toxicity, but during ingestion they pose a

serious risk of pulmonary aspiration. Hydrocarbons destroy pulmonary surfactant, leading to

ventilation- perfusion mismatch, hypoxia.

Manifestations

- Prolonged cough, gasping, or choking following ingestion often indicates aspiration

- Respiratory distress within 2-6 hours in case of aspiration

- Fever due to direct tissue toxicity

Treatment

- Gastric lavage

- Asymptomatic patient after 4-6 hours will be discharge

2. CAUSTIC AGENTS ( Acids or Alcalins)

Caustic agents which cause direct tissue injury, are present in many household. Ingested caustic

agents include dishwasher detergents, swimming pool and toilet bowel cleaners, battery acids.

Acids cause a caogulative necrosis which tends to limit tissue damage, in contrast, alcalines

cause liquefactive necrosis with penetration into the deeper tissues, resulting in extensive tissue

damage.


Manifestations

- Severe pain

- Spontaneous vomiting

- Injury to the esophagus from alkalines has been graded.

*Grade I: injury, mucosal hyperhemia without ulceration.

*Grade II: burns, with submucosal lesions and ulcerations.

*Grade III: burns, with deep ulcers and tissue necrosis. There is risk for perforation.

- The chest and abdominal X- ray may show esophageal or gastric perforation.

Treatment

- Dilution with milk or water may be helpful if given within the 1st few minutes after the

exposure in those who have no airway complains, vomiting, no abdominal pain, and are

able to speak.

III. INGESTION OF DRUG OVERDOSAGE

Drug overdose is common among children less than 6 years of age. Poisoning due to drug

overdose may be local (e.g., skin, eyes, or lungs) or systemic depending on the chemical and

physical properties of the poison, its mechanism of action, and the route of exposure.

Management

Treatment goals include:

Support of vital signs,

Prevention of further poison absorption,

Enhancement of poison elimination,

Administration of specific antidotes,

and prevention of reexposure.


a) Supportive care

Airway protection

Oxygenation/ventilation

Treatment of arrhythmias

Hemodynamic support

Treatment of seizures

Correction of temperature abnormalities

Correction of metabolic derangements

Prevention of secondary complications

a) Prevention of Further Poison Absorption

Gastrointestinal decontamination

Syrup of ipecac–induced emesis

Gastric lavage

Activated charcoal

Whole-bowel irrigation

Dilution

Endoscopic/surgical removal

Decontamination of other sites

Eye decontamination

Skin decontamination

Body cavity evacuation

Enhancement of Poison Elimination

Multiple-dose activated charcoal

Diuresis

Alteration of urinary pH

Extracorporeal removal

Peritoneal dialysis


Hemodialysis

Hemoperfusion

Hemofiltration

Plasmapheresis

Exchange transfusion

Hyperbaric oxygenation

Administration of Antidotes

Neutralization by antibodies

Neutralization by chemical binding

Metabolic antagonism

Physiologic antagonism

Prevention of Reexposure

Education of older children

Child-proofing

Psychiatric referral in case of suicide attempt

ACETAMINOPHEN OVERDOSAGE

Acetaminophen ( Paracetamol ) is the most common pharmaceutical agent involved in overdose.

Clinical features

An acute ingestion 150-200mg/kg of acetaminophen in a child is potentially hepatotoxic.

Early after the acute overdose, there are minor symptoms like: Nausea, vomiting and

anorexia.

Approximately 36 hours after ingestion: * transaminase levels rise, *Encephalopathy,

*metabolic acidosis, *increasing prothrombin time.


Differential diagnosis

Viral hepatitis

Hepatobiliary disease

Management

Activated charcoal within1-2 hours

Give N-acetylcystein within8 hours of ingestion to prevent hepatotoxicity. Oral or via

nasogastric tube 140mg/kg loading dose, then 70mg/kg every 4 hours for 17 doses.

Antiemetics may be necessary

Clinical Features and Associated Poisons (Toxidromes)


Clinical Features Poisons

Odour of Breath Chloroform, Ethanol, Cyanide, Arsenic,

Organophosphates, Phosphorus, Kerosene

Hypertension

with Tachycardia

Amphetamines, Cocain, MAO inhibitors,

Marijuana, Phencyclidine, Alcohol

withdrawal,

Nicotine, Antihistamines, Antipsychotic

agents,antidepressants

Hypotension with

bradycardia

Aluminium phosphide, Antipsychotics,

Caffeine,

Cyanide, Disulfiram-ethanol interaction,

Tricyclic

antidepressants

Hyperthermia Amoxapine, Amphetamines, Antidepressants,

Cocaine, Lithium , MAO inhibitors,

Phencyclidine,

Anticholinergic agents, Salicylates,

Antihistamines

Hypothermia Antidepressants, Ethanol, Benzodiazepine,

Narcotics,

Barbiturates, Phenothiazines

Tachypnoea Amphetamines, Atropine, Cocaine,

Salicylates,Carbon monoxide, Cyanide,

Hepatic

Encephalopathy (paracetamol, amatoxin

mushrooms), Metabolic acidosis

Bradypnoea Antidepressants, Antipsychotic agents,

Barbiturates, Ethanol, Benzodiazepines,

Chlorinated hydrocarbons, Narcotics,

Nicotine,

Organophosphates, Cobra bites

Altered sensorium Antidepressants, Antihistamines,

Antipsychotics,

Atropine, Organophosphates, Barbiturates,

Lithium,

Cyanide, Benzodiazepines, Ethanol,

Narcotics,

paediatrics notes 3 update pdf

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