Paeds Notes (G.Patil) PDF

Paediatrics Notes Bhalani IMP’S Answers By Dr.G.Patil GMC Nagpur Microcephaly Definition : Head circumference 3 SD below the mean is more likely to be associated with genetic and non- genetic disorders affecting brain than if defined as >2 SD below the mean, since the latter may...

Paediatrics Notes Bhalani IMP’S Answers By Dr.G.Patil GMC Nagpur Microcephaly Definition : Head circumference 3 SD below the mean is more likely to be associated with genetic and non- genetic disorders affecting brain than if defined as >2 SD below the mean, since the latter may include intellectually normal healthy children with head circumference at the lower end of the population distribution. Primary causes Secondary causes Familial Congenital infections: CMV, Rubella, Toxoplasmosis Cri du chat syndrome Maternal causes : Alcohol, Smoking, Phenytoin, Radiation, Edward syndrome Phenylketonuria, Diabetes Patau syndrome Acquired microcephaly : Rett syndrome, Angelman syndrome, Seckel syndrome, Zika virus infection, Infections in infancy : Meningitis, Encephalitis Malnutrition Investigations Evaluation for microcephaly should be initiated if a single head circumference measurement is more than 2-3 SD below the mean or when serial measurements reveal progressive decrease in head size. Careful history and physical examination are necessary, including development assessment and measurement of head size of parents. Need for neuroimaging is determined by the age at onset, severity of microcephaly, head circumference in parents, history of antenatal insult(s) and associated clinical features. Pica Most common behavioral problem in children less than 5 years of age Persistent craving and compulsive eating of nonnutritive, nonedible substances over a period of atleast 1 month Common substances include plaster, charcoal, paint, chalk, and earth (Geophagia) Other less common non-edible substances like dust, clay, sand, and ice (pagophagia) The action is inappropriate to developmental level of the child and culturally unacceptable More common in children with intellectual disability and autism Etiology Mental retardation Psychosocial stress—maternal deprivation, parent neglect, abuse Poor socioeconomic status Malnutrition Iron deficiency anemia Clinical associations: Lead poisoning Parasitic infections Iron deficiency anemia Mental retardation Vitamin and micronutrient deficiencies Pseudotumor cerebri Trichotillomania Management- Alleviating psychosocial stress Deworming Treatment of Iron deficiency—iron supplementation and limiting cow’s milk intake Thumb Sucking Thumb sucking is normal behavior in infants and toddlers. It peaks between the ages of 18-21 months and most children spontaneously drop the habit by 4 yr of age. Its persistence in older children is socially unacceptable and can lead to dental malignancies. Parents should be reassured and asked to ignore the habit if the child is younger than 4 yr of age. If it persists beyond the age of 4-5 yr, the parents should motivate the child to stop thumb sucking and encourage him when he restrains himself from sucking the thumb. Application of noxious agents over the thumb is useful as an adjunctive second-line treatment. Adolescence- SMR,Health Problems Def :- “The sequence of events by which the individual is transformed into a young adult by a series of biological changes”. Stages of adolescence Early adolescence (10–13 years) - Characterized by a ‘spurt of growth’ and development of secondary sexual characteristics Mid adolescence (14–16 years) - Development of a separate identity from parents, experimentation, new relationships with peer groups, and opposite sex. Late adolescence (17–19 years) - Fully developed physical characteristics similar to adults. They have a distinct identity, well-formed opinions and ideas. Important Health problems during adolescence Illness - 1) Problems related to growth and development like precocious or delayed puberty and short stature  2)Endemic infectious diseases like TB, malaria etc Consequences of risk taking behavior - 1)Unintended injuries—Automobile and sports related accidents 2)Intended injuries—Violence, homicide, suicide 3)Sexually transmitted diseases—HIV/AIDS, Herpes, UTI 4)Substance abuse—Tobacco, alcohol, drug abuse Nutritional problems - 1)Undernutrition 2)Micronutrient deficiencies like iron deficiency anemia, iodine deficiency 3) Obesity 4) Eating disorders Reproductive health problems - 1)Unprotected sexual intercourse 2)Teenage pregnancies 3)High maternal mortality 4) High perinatal mortality, high LBW rate 5)Abortion related problems 6) Menstrual problems 7)Reproductive tract infections Mental health and related problems - 1. Behavior disorders 2. Stress, anxiety 3.Depression and suicide 4. Substance use 5. Violent behavior 6. Eating disorders—Bulimia and anorexia nervosa Tanner staging/Sexual maturity rating (SMR) Girls: Stage Breast Pubic hair 1 No breast tissue Same as abdominal hair 2 Breast bud, enlargement Minimally pigmented, mainly over labia Of areola 3 Further enlargement of Darker and coarser hair on mons pubis breast bud and areola 4 Secondary mound formed Adult type, less distribution by papilla and areola 5 Adult contour with projection Adult feminine distribution with spread to medial surface of thigh of papilla alone First visible sign of puberty is the Thelarche. It occurs between 8 and 12 years Menses begins 2–2.5 years after thelarche (during SMR 3–4) Growth spurt occurs in Tanner stage 3 Boys: Stage Genital changes Testicular volume Pubic hair 1 Prepubertal 20 mL Adult male distribution First visible sign of puberty is testicular enlargement It begins around 9–10 years Testicular volume is assessed using an orchidometer Growth spurt occurs in SMR 4 or when the testis volumes reach approximately 10–15 ml Psychological Problems during Adolscence 1. Depression :- - “acute depressive reactions” are a sort of healthy grief response following death or separation from a loved one. These resolve in due course of time,occasionally after weeks or months. - “Neurotic depressive disorders” are unresolved grief reaction and are characterized by a feeling of guilt in relationship to the dead. A psychiatric treatment is in order. - “Masked depression” is characterized by denial and somatization of feelings of despair, hopelessness and helplessness by the adolescent. - Manifestations include “acting-out” behavior in the form of substance abuse, school truancy, running away from home, multiple accidents, unexplained headache, abdominal pain, etc. A psychiatric treatment is mandatory. 2. Sucide :-  - Suicide is one of the important causes of deaths among adolescents. - Its causes include serious conflicts and pressures, successive failures in examination, marriage against will, chronic illnesses causing fear of fatality, impotence, diminished competence, poor self-image, vulnerability to loss of a loved one and easy and increased access to medication that could facilitate suicide. - Any suicidal attempt is an indication for a psychiatric evaluation and management. - A short-term hospitalization is of distinct value in providing a secure environment to the subject and helps the individual in the constructive resolution of his conflict 3. Substance Abuse :- CNS stimulants (dexedrine, methedrine) CNS depressants (opiates) Hallucinogens (LSD, phenylcyclidine, mushrooms, datura) Volatile substances (gasoline sniffing, airplane glue, nitrites), Marijuana (hashish), cocaine, alcohol, smoking, anabolic steroids - The most important preventive measure is channelization of the energy of the adolescents and creating awareness in them about the adverse effect of substance abuse Metabolic Acidosis in Children Metabolic acidosis is characterized by decrease in serum pH that results from. 1. Loss of bicarbonate. 2. Elevated H+ ions or decreased excretion of acids. Primary metabolic acidosis is characterized by an arterial pH of less than 7.35 in the absence of an elevated PaCO2. Causes of metabolic acidosis: Normal anion gap 1) Diarrhea 2)Renal tubular acidosis 3) Acetazolamide therapy 4)Urinary tract diversion (uretero- sigmoidostomy, rectourethral fistula) High anion gap 1)Diabetic ketoacidosis, starvation ketoacidosis 2)Lactic acidosis, shock, severe anemia, liver failure. 3)Poisoning: Salicylate, Paraldehyde, Methanol,Ethylene glycol 4)Uremia, Inborn errors of metabolism 5) Medications: Metformin, propofol. Clinical features Mild metabolic acidosis presents with nausea, vomiting, headache, and abdominal pain Severe cases present with Kussmaul’s breathing (rapid and deep respiration), tachycardia, cerebral vasodilatation leading to increased ICP, altered mentation and coma. Chronic cases present with Anorexia, lethargy, poor weight gain and listlessness. Chronic acidemia  also results in osteopenia and muscle wasting as a result of release of calcium carbonate and glutamate respectively as buffers for H+ Management Underlying cause should be identified and treated first. Shock should be treated with aggressive fluid therapy and adequate oxygenation. Vasoactive agents (dopamine, dobutamine) should be added only after volume replacement as they can worsen acidosis. Routine IV sodium bicarbonate for metabolic acidosis is not recommended SAM – c/f, complications , management Diagnostic criteria (any one of the following) 1) Weight for height < 70% of expected or < −3 Z score 2) Visible wasting 3) Bilateral pitting type of edema 4) MUAC