Current Paediatrics

By A. Bader

This book, Current Paediatrics, radically offers a new way for medical students, paediatric specialist trainees, paediatricians, and paediatric nurses to access practical management advice. It provides indispensable guides to day-to-day child’s care on the paediatric ward, paediatric intensive care unit, and paediatric outpatient clinic.

This book
• provides first point of call for paediatric doctors facing infants and children with acute or chronic medical and surgical problems,
• provides a simple description of the common medical and surgical paediatric practical procedures that need to be done by the paediatric doctors and nurses,
• deals with common medical and surgical problems seen by paediatricians and rarer conditions more often seen at tertiary paediatric unit,
• is presented in a readily accessible format (with extensive use of bullet points), and
• focuses on clinical presentation, diagnosis, and management of the common paediatric medical and surgical problems.

Contents
1. The immunizations
2. Fluids and acid base
3. Medical emergencies
4. Cardiovascular disorders
5. Respiratory disorders
6. Allergic disorders
7. Endocrine disorders
8. Metabolic disorders
9. Genetic conditions
10. Gastrointestinal disorders
11. Hematologic disorders
12. Neoplastic disorders
13. Immunodeficiency disorders
14. Infectious diseases
15. Renal disorders
16. Rheumatologic disorders
17. Neurologic disorders
18. Psychiatric and behavioural disorders
19. Child protection
20. Orthopaedic conditions
21. Ophthalmologic disorders
22. Ear, nose, and throat disorders
23. Gynaecologic disorders
24. Dermatologic disorders
25. Surgical disorders

• Language: English
• Publisher: Balboa Press
• Release date: Oct 25, 2018
• ISBN: 9781982206383

A. Bader

CURRENT PAEDIATRICS Abdulgader Bader MBchB, DCH, MD, CABP, MRCP (London), CCST (UK), MRCPCH (UK), FRCPCH (UK) Senior Consultant Paediatric Pulmonologist & Neonatologist, Benghazi Medical Center, Benghazi, Libya Head of Paediatrics and Medical Director, Mediclinic Al-Jowhara Hospital, Al-Ain, UAE Honorary Clinical Lecturer, University of Liverpool Assistant Professor, Faculty of Medicine, Benghazi University and Libyan International Medical University, Benghazi, Libya NLS Instructor, UK Resuscitation Council Secretary of Libyan Society of Paediatric Respiratory, Allergy & Clinical Immunology (LSPRACI)

Book preview

Copyright © 2018 A. Bader.

All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews.

This book is a work of non-fiction. Unless otherwise noted, the author and the publisher make no explicit guarantees as to the accuracy of the information contained in this book and in some cases, names of people and places have been altered to protect their privacy.

Balboa Press

A Division of Hay House

1663 Liberty Drive

Bloomington, IN 47403

www.balboapress.com

1 [phone]

Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

The author of this book does not dispense medical advice or prescribe the use of any technique as a form of treatment for physical, emotional, or medical problems without the advice of a physician, either directly or indirectly. The intent of the author is only to offer information of a general nature to help you in your quest for emotional and spiritual well-being. In the event you use any of the information in this book for yourself, which is your constitutional right, the author and the publisher assume no responsibility for your actions.

Any people depicted in stock imagery provided by Getty Images are models,

and such images are being used for illustrative purposes only.

Certain stock imagery © Getty Images.

ISBN: 978-1-9822-0637-6 (sc)

ISBN: 978-1-9822-0638-3 (e)

Balboa Press rev. date: 10/16/2018

Symbols and Abbreviation

• AAAAI: American Academy of Allergy, Asthma & Immunology

• AAF: Amino Acid Formula

• AAP: The American Academy of Pediatrics

• ABPA: Allergic Bronchopulmonary Aspergillosis

• ABPM: Ambulatory Blood Pressure Measurements

• ABU: Asymptomatic Bacteriuria

• ACCM-PALS: American College of Critical Care Medicine–Pediatric Advanced Life Support

• ACE: Acute Cerebral Oedema

• ACM: Arnold-Chiari Malformation

• ADEM: Acute Disseminated Encephalomyelitis

• ADHD: Attention Deficit and Hyperactive Disorder

• ADR: Adverse Drug Reactions

• AED: Anti-Epileptic Drugs

• AEDs: Automatic External Defibrillators

• AF: Aspergillus Fumigatus

• AGE: Acute Gastroenteritis

• AHA: The American Heart Association

• AHC: Anterior Horn Cells

• AHT: Anti-Hypertensives

• AIDS: Acquired Immune Deficiency Syndrome

• AIHA: Autoimmune Haemolytic Anaemia

• AIS: Adolescent Idiopathic Scoliosis

• AITs: Immunotherapy Tablets

• AKI: Acute Kidney Injury

• AL: Argininosuccinate lyase

• ALI: Acute Lung Injury

• ALL: Acute Lymphoblastic Leukaemia

• ALP: Alkaline phosphatase

• ALT: Alanine aminotransferase

• ALTE: Apparent Life-Threatening Event

• AML: Acute Myeloid Leukaemia

• ANA: Antinuclear Antibodies

• ANCA: Anti-Neutrophil Cytoplasmic Antibodies

• AOM: Acute Otitis Media

• APLS: Advanced Paediatric Life Support

• APT: Atopy Patch Testing

• AR: Allergic Rhinitis

• AR: Aortic Regurgitation

• ARDS: Acute Respiratory Distress Syndrome

• ARF: Acute renal failure

• ARIA: Allergic Rhinitis and its Impact on Asthma

• ART: Anti-Retroviral Therapy

• AS: Aortic Stenosis

• AS: Argininosuccinate Synthetase

• ASA: Acute Septic Arthritis

• ASD: Atrial Septal Defect

• ASD: Autism Spectrum Disorder

• ASO: Antistreptolysin-O

• AST: Aspartate aminotransferase

• AT: Ataxia Telangiectasia

• AVNRT: Atrio-Ventricular Nodal Re-entry Tachycardia

• AVRT: Atrio-Ventricular Re-entry Tachycardia

• AVSD: Atrioventricular Septal Defects

• BAL: Bronchoalveolar lavage

• BAPM: The British Association of Perinatal Medicine

• BCG: Bacille Calmette-Guérin

• BH4: Tetrahydrobioptrin deficiency

• BMI: Body Mass Index

• BNF: British National Formulary

• BO: Bronchiolitis Obliterans

• BP: Blood Pressure

• BPD: Broncho-Pulmonary Dysplasia

• BSACI: The British Society of Allergy and Clinical Immunology

• BTS: British Thoracic Society

• BTX-A: Botulinum toxin A injections

• BVH: Biventricular Hyperatrophy

• CAH: Congenital Adrenal Hyperplasia

• CAL: Caffe-Au-Lait

• CAMHS: Child and Adolescent Mental Health Services

• CAP: Community Acquired Pneumonia

• CARP: Confluent and Reticulated Papillomatosis

• CAT: Common Arterial Trunk

• CAVB: Complete Atrio-Ventricular Block

• CBF: Cerebral Blood Flow

• CBF: The ciliary beat frequency

• CCAM: Congenital Cystic Adenomatoid Malformation

• CCHS: Congenital Central Hypoventilation Syndrome

• CD : Coeliac Disease

• CDC: The Centres for Disease Control

• CDGA: Constitutional Delay of Growth and Adolescence

• CF: Cystic Fibrosis

• CFM: Cerebral Function Monitoring

• CFUs/ml: Colony-Forming Units per Milliliter

• CGD: Chronic Granulomatous Disease

• CH: Cystic Hygroma

• CHD: Congenital Heart Disease

• CHD: Congenital Heart Disease

• CHI: Congenital Hyperinsulinism of Infancy

• CLE: Congenital Lobar Emphysema

• CLL: Chronic Lymphoblastic Leukaemia

• CM: Cow’s Milk

• CMI: Cell Mediated Immunity

• CML: Chronic Myeloid Leukaemia

• CMP: Cow’s Milk Protein

• CMPA: Cow’s Milk Protein Allergy

• CMV: Cytomegalovirus

• CMZ: Carbamazepine

• CNO: Chronic Non-Bacterial Osteomylitis

• CNS: Central Nervous System

• CO: Carbon Monoxide

• COLA: Cystine, Ornithine, Lysine and Argenine

• CONI: Care of Next Infant

• CP: Cerebral Palsy

• CPP: Cerebral Perfusion Pressure

• CPR: Cardiopulmonary Resuscitation

• CPS: Carbamyl Phosphate Synthetase

• CPT: Carnitine Palmitoyltransferase

• CRI: Chronic Renal Insufficiency

• CRP: C-Reactive Protein

• CSE: Convulsive Status Epilepticus

• CSF: Cerebrospinal Fluid

• CT: Computed Tomography

• CVS: Cardiovascular System

• CVS: Cyclical Vomiting Syndrome

• CXR: Chest x.ray

• DBS: Deep Brain Stimulation

• DDH: Developmental Dysplasia of the Hip

• DIC: Disseminated Intravascular Coagulation

• DKA: Diabetic Ketoacidosis

• DM: Diabetes Mellitus

• DMARD: Disease-modifying antirheumatic drug

• DMSA: technetium-99m–DimercaptosuccinicAcid

• DORV : Double Outlet Right Ventricle

• DPI: Dry Powder Inhalers

• DTaP: Diphteria, tetanus,and acellular pertussis,

• E coli: Escherichia coli

• EBM: Expressed Breast Milk

• EBV: Epstein-Barr Virus

• ECA: Endothelial Cell Antibodies

• ECMO: Extra Corporeal Membrane Oxygenation

• EDF: End Diastolic Flow

• EEG: Electroencephalography

• EHF: Extensively Hydrolysed Formula

• EIA: Exercise Induced Asthma

• EIA: Exercise-induced Anaphylaxis

• ELS : Extralobar sequestration

• EM: Electron Microscopy

• EM: Erythema Multiforme

• EMG: Electromyogram

• ENT: Ear Nose & Throat

• EPIT: Epicutaneous Immunotherapy

• ERC: The European Resuscitation Council

• ERG: Electroretinogram

• ESM: Ejection Systolic Murmur

• ESPGHAN: The European Society for Paediatric Gastroenterology, Hepatology and Nutrition

• ESPID: The European Society of Paediatric Infectious Disease

• ESR: Erythrocyte Sedimentation Rate

• ETN: Etanercept

• ETT: Endo-Tracheal Tube

• FBC: Full Blood Count

• FBAO: Foreign Body Airway Obstruction

• FCT: Faecal CalprotectinTest

• FDA: Food and Drug Administration

• FDEIA: Food-dependent Exercise-induced Anaphylaxis

• FEF: Forced Expiratory Flow

• FENO: Fractional exhaled Nitric Oxide

• FEV1: Forced expiratory volume in 1 second

• FFP: Fresh Frozen Plasma

• FGID: Functional gastro-intestinal disorder

• FHH: Familial Hypocalciuric Hypercalcaemia

• FISH: Fluorescent In Situ Hybridization

• FNP: Facial Nerve Palsy

• FOP: Fibrodysplasia Ossificans Progressiva

• FPIES: Food Protein-Induced Enterocolitis Syndrome

• FRC: Functional Residual Capacity

• FSE: Febrile Status Epilepticus

• FSGS: Focal Segmental Glomerulosclerosis

• FSH: Follicle Stimulating Hormone

• FSHR: Follicle Stimulating Hormone Receptor

• FTT: Failure To Thrive

• FVC: Forced Vital Capacity

• GABHS: Group A beta haemolytic Streptococci

• GBS: Gillian Barre Syndrome

• GBS: Group B Streptococcus

• GCS: Glasgow Coma Score

• GDG: The Guideline Development Group

• GFR: Glomerular Filtration Rate

• GH: Growth Hormone

• GIT: Gastro-intestinal tract

• GMSPS: Glasgow Meningococcal Septicaemia Prognostic Score

• GOR: Gastro-Oesophageal Reflux

• GTCS: Generalised Tonic Clonic Seizures

• GTT: Glucose tolerance Test

• GVHD: Graft Versus Host Disease

• HAE: Hereditary Angioneurotic Oedema

• HAV: Hepatitia A virus

• HBcAg: Hepatitis B core antigen

• HBeAb: Hepatitis B e antibody

• HBeAg: Hepatitis B e antigen

• HBIG: Hepatitis B immune globulin

• HBoV: Human Bocavirus

• HBsAb: Hepatitis B surface antibody

• HBsAg: Hepatitis B surface antigen

• HBV: Hepatitis B virus

• HBV: Hepatitis B vaccine

• HCC: Hepatocellular carcinoma

• HCV: Hepatitis C virus

• HD: Hodgkin’s Disease

• HDV: Hepatitis D virus

• HEV: Hepatitis E virus

• HFNC: High Flow Nasal Cannulae

• HFOV: High Frequency Oscillatory Ventilation

• HiB: HaemophilusInfluenza type b

• HIE: Hypoxic Ischemic Encephalopathy

• HIV: Human immunodeficiency virus

• HLHS: Hypoplastic Left Heart Syndrome

• HMD: Hyaline Membrane Disease

• HMP: Human Metapneumoviruses

• HOCM: Hypertrophic Obstructive Cardio-Myopathy

• HPF: High-Power Field

• HPV: Human Papilloma Virus

• HRCT: High Resolution Computed Tomography

• HSFC: The Heart and Stroke Foundation of Canada

• HSP: Henoch-Schonlein Purpura

• HSP: Henoch-Schonlein Purpura

• HSV: Herpes Simplex Viruses

• HT: Hypertension

• HUS: Haemolytic-Uremic Syndrome

• IBD: Inflammatory Bowel Diseases

• IBS: Irritable Bowel Syndrome

• ICP: Intracranial Pressure

• ICS: Inhaled Corticosteroids

• IFN-a: Interferon alfa

• Ig: Immunoglobulins

• IGRA: Interferon-gamma release assays

• IH: Infantile Haemangioma

• IHPS: Infantile Hypertrophic Pyloric Stenosis

• IHs: Infantile Hemangiomas

• ILAR: The international League of Associations of rheumatology

• ILCOR: The International Liaison Committee on Resuscitation

• ILD: Interstitial Lung Disease

• ILEA: International League Against Epilepsy

• ILS : Intralobar Sequestration

• IM: Intramuscular

• IMD: Inherited Metabolic Diseases

• IMD: Invasive meningococcal disease

• INH: Isoiniazid

• IPPV: Intermittent Positive Pressure Ventilation

• IPV: Injection polio vaccine

• IRT: Immune-Reactive Trypsin

• IS: Intraosseous

• ISAAC: The International Study of Asthma and Allergies in Childhood

• ITB: Intrathecal Baclofen Pumps

• ITP: Idiopathic Thrombocytopenic Purpura

• IUGR: Intra-Uterine Growth Retardation

• IV: Intravenous

• IVC: Inferior Vena Cava

• IVIG: Intravenous Immune Globulin

• JIA: Juvenile Idiopathic Arthritis

• JORRP: Juvenile Onset Recurrent Respiratory Papillomatosis

• kCO: Transfer Factor

• KD: Kawasaki Disease

• kPa: kilopascals

• LCPUFA: Long- Chain Polyunsaturated Fatty acids

• LCT: Long Chain Triglycerides

• LD: Learning Difficulty

• LDH: Lactate Dehyrogenase

• LFTs: Liver function tests

• LH: Luteinising hormone

• LHR: Luteinising Hormone Receptor.

• LM: Light Microscopy

• LMN: Lower Motor Neuron

• LN: Lichen Nitidus

• LP: Lichen Planus

• LP: Lumbar puncture

• LRTI: Lower Respiratory Tract Infection

• LS: Lichen Striatus

• LTEC: Laryngotracheo-oesophageal cleft

• LTRA: Leukotriene Receptor Antagonists

• LTV: Long Term Ventilation

• LVH: Left Ventricular Hyperatrophy

• LVOT: Left Ventricular Outlet

• MaH: Macroscopic Haematuria

• MAS: Meconium Aspiration Syndrome

• mcg: Microgram

• MCNS: Minimal Change Nephrotic Syndrome

• MCT: Medium Chain Triglycerides

• MCUG: Micturating Cysto Urethrogram

• MDEM: Multiphasic Disseminated Encephalomyelitis

• MDR-TB: Multi-drug Resistant Tuberculosis

• MeCP2: Methyl-CpG-binding protein 2

• Men C: Meningococcal C

• mg: Milligram

• MiH: Microscopic Haematuria

• min: Minute

• MLD: Metachromatic Leukodystrophy

• MLD: Moderate Learning Difficulties

• MLS: Middle Lobe Syndrome

• MMR: Measles, Mumps, Rubella

• MODY: Maturity Onset Diabetes of Youth

• MPV: Metapneumovirus

• MRI: Magnetic Resonance Imaging

• MRSA: Methicillin Resistance Staphylococcus Aureus

• MS: Multiple Sclerosis

• MSAF: Meconium Staining of the Amniotic Fluid

• MTB: Mycobacterium Tuberculosis

• MTCT: Mother Transmission, Child Transmission

• Mtx: Methotrexate

• NAI: Non-Accidental Injury

• NASI: Non-Accidental Skeletal Injury

• NASPGHAN: The North American Society for Paediatric Gastroenterology, Hepatology and Nutrition

• N-BiPAP: Nasal bi-level Positive Airway Pressure

• NBT: Nitrobluetetrazolium test.

• N-CPAP: Nasal Continuous Positive Airway Pressure

• NCS: Non-Convulsive Status

• NEBA: The Neuropsychiatric EEG-Based Assessment Aid

• NEC: Necrotising Enterocolitis

• NEH: Neuroendocrine Hyperplasia

• NF1: Neurofibromatosis type 1

• NF2: Neurofibromatosis type 2

• ng: Nanogram

• NG: Naso-gastric

• NGT: Naso-gastric Tube

• NHL: Non-Hodgkin’s Lymphoma

• NICE: National Institute for Health and Clinical Excellence

• NICU: Neonatal Intensive Care Unit

• N-IPPV: Nasal Intermittent Positive Pressure Ventilation

• NIV: Non-Invasive Ventilation

• NO: Nitric Oxide

• NREM : Non-Rapid Eye Movement

• NS: Nephrotic Syndrome

• NSAID: Non steroidal anti-inflammatory drugs

• NTHi : Non-typableHaemophilusinfluenzae

• NTM: Non-tuberculous mycobacteria

• O2: Oxygen

• OAS: Oral Allergy Syndrome

• OFC: Occipto-Frontal Circumference

• OFC: Oral Food Challenge

• OGD: Oesophago-gastro-duodenoscopy

• OGTT: Oral Glucose Tolerance Test

• OI: Osteogenesis Imperfecta

• OIT: Oral Immunotherapy

• OM: Otitis Media

• OME: Otitis Media with Effusion

• OP: Organizing Pneumonia

• OPV: Oral Polio Vaccine

• ORS: Oral Rehydration Solution

• ORT: Oral Rehydration Therapy

• OSA: Obstructive Sleep Apnoea

• OTC: Ornithine Transcarbamylase

• PA: Pulmonary Artery

• PA: Pulmonary Atresia

• PAF: Platelets Activating Factor

• PAH: Pulmonary Arterial Hypertension

• PAS: Para-Aminosalicylic acid

• PBB: Protracted Bacterial Bronchitis

• PC: Pectus Carinatum

• PCD: Primary Ciliary Dyskinesia

• PCH: Paroxysmal Cold Haemoglobinuria

• PCP: Pneumocystis Pneumonia

• PCR: Polymerase chain reaction

• PCT: Procalcitonin

• PCV: Pneumococcal Conjugate Vaccine

• PDA: Patent DuctusArteriosus

• PDL: Pulse Dye Laser

• PE: Pectus Excavatum

• PEA: Pulseless Electrical Activity

• PEEP: Positive End Expiratory Pressure

• PEFR: Peak Expiratory Flow Rates

• PFS: Pollen Food Syndrome

• PG: Prostaglandin

• PHF: Partially Hydrolysed Formulae

• PHT: Pulmonary Hypertension

• PICU: Paediatric Intensive Care Unit

• PIE: Pulmonary Interstitial Emphysema

• PIG: Pulmonary Interstitial Glycogenesis

• PIGN: Post-Infectious Glomerulonephritis

• PIP: Peak Inspiratory Pressure.

• PIV: Parainfluenza Viruses

• PIV: Parainfluenza Viruses (PIV)

• PJRT: Permanent Junctional Reciprocating Tachycardia

• PKU: Phenyl Ketone Urea

• PLMS: Periodic Limb Movements in Sleep

• PMDI: Pressure Meter Dose Inhaler

• PMDI: Pressurized Metered-Dose Inhalers

• PNET : Primitive Neuroectodermal Tumours

• PNH: Paroxysmal Nocturnal Haemoglobinuria

• PPB: Parts per billion

• PPD: Purified Protein Derivatives

• PPE: Parapneumonic effusion

• PPHN: Persistent Pulmonary Hypertension of the Newborn

• PPI: Proton Pump Inhibitor

• PPV: Pneumococcal Polysaccharide Vaccine

• PPV: Positive Pressure Ventilation

• PROM: Prolonged rupture of membranes

• PRV: Polycythaemia Rubra Vera

• PS: Pulmonary Stenosis

• PSGN: Poststreptococcal glomerulonephritis

• PT: Prothrombin time

• PTH: Parathyroid Hormone

• PUD: Peptic Ulcer Disease

• PUJ: Pelviureteric Junction Obstruction

• PUV: Posterior Uretheral Valve

• PVR: Peripheral Vascular Resistance

• PWS: Prader-Willi Syndrome

• QTc: Correcte QT Interval

• RA: Right Atrium

• RAH: Right Atrial Hypertrophy

• RAP: Recurrent Abdominal Pain

• RB: Retinoblastoma

• RBBB: Right Bundle Branch Block

• RCSA: The Resuscitation Council of South Africa

• RDS: Respiratory Distress Syndrome

• REM : Rapid Eye Movement

• RFT: Renal function test

• RIF: Rifampicin

• RPD: Renal Parenchymal disease

• RSMF: Rocky Mountain Spotted Fever

• RSV: Respiratory Syncytial Virus

• RTA: Road Traffic Accident

• RUT: Rapid Urease Test

• RV: Residual Volume

• RV: Right Ventricle

• RVH: Right Ventricular Hyperatrophy

• RVO: Right Ventricular Outflow

• RVOT: Right Ventricular Outlet

• SALT: Speech and Language Therapist

• SARS: Severe Acute Respiratory Syndrome

• SBP: systolic Blood Pressure

• SC: Subcutaneously

• SCID: Severe Combined Immune Deficiency

• SCIT: Subcutaneous Immunotherapy

• SDNS: Steroid Dependent Nephrotic Syndrome

• SDR: Selective Dorsal Rhizotomy

• SE: Side Effects

• SIADH: Syndrome of inappropriate ADH secretion

• SIDS: Sudden Infant Death Syndrome

• sIgE: Serum specific IgE

• SIGN: Scottish Intercollegiate Guidelines Network

• SIT: Specific Immunotherapy

• SLD: Severe Learning Difficulties

• SLE: Systemic Lupus Erythematosus

• SLIT: Sublingual Immunotherapy

• SMA: Spinal Muscular Atrophy

• SND: Sinus Node Dysfunction

• SNE: Subacute Necrotizing Encephalopathy

• SoJIA: Systemic-onset Juvenile Idiopathic Arthritis

• SOL: Space Occupying Lesion

• SPA: Supra Pubic Aspirate

• SPT: Skin Prick Test

• SRNS: Steroid Resistant Nephrotic Syndrome

• SRS: Silver–Russell syndrome

• SSNS: Steroid Sensitive Nephrotic Syndrome

• SSPE: Subacute sclerosing panencephalitis

• SSRI: Selective Serotonin Reuptake Inhibitor

• SSSS: Staphylococcal Scalded Skin Syndrome

• Staph-tss: Staphylococcal toxic shock syndrome

• Strep-TSS: Streptococcal toxic shock syndrome

• SUDEP: Sudden Unexpected Death in Epilepsy

• SUFE: Slipped Upper Femoral Epiphysis

• SVC: Superior Vena Cava

• SVP: Sodium Valproate

• SVT: Supra-Ventricular Tachycardia

• T dap: Tetanus, diphtheria, and acellular pertussis

• T1DM: Type 1 Diabetes Mellitus

• T2D: Type 2 Diabetes

• TA: Tricuspid Atresia

• TAPVC: Total Anomalies of Pulmonary Venous Connection

• TB: Tuberculosis

• TBBD: Temporary Brittle Bone Disease

• TBM: Tracheobronchomalacia

• TBM: Tuberculous Meningitis

• TCA: Tricyclic Antidepressant

• TCS: Treacher-Collins Syndrome

• TCS: Topical Corticosteroids

• TEV: Talipes Equinovarus

• TEW: Transient Episodic wheeze

• TGA: Transverse of Great Arteries

• TIBC: Total Iron Binding Capacity

• TLC: Total Lung Capacity

• TLCO: Total Lung Carbon Monoxide

• TOF: Tetrology Of Fallots

• TOF: Trachea-Oesophageal Fistula

• TPA: Tissue Plasminogen Activator

• TPN: Total Parental Nutrition

• TRH: Thyrotrophin-Releasing Hormone

• TS: Tuberous Sclerosis

• TSNS: Tumours of the Sympathetic Nervous System

• TST: Tuberculin Skin Test

• TTN: Transient Tachypnoea of the Newborn

• TV: Tidal Volume

• UBT: Urea Breath Test

• UK: United Kingdom

• UMN: Upper Motor Neuron

• UOP: Urine Out Put

• URTI: Upper Respiratory Tract Infection

• USA: United States of America

• USS: Ultrasound

• UTI: Urinary Tract Infection

• UVB: Ultraviolet B Radiation

• VA: Alveolar Volume (VA)

• VATS: Video-Assisted Thoracoscopic Surgery

• VCD: Vocal Cord Dysfunction

• VF: Ventricular fibrillation

• VHC: Valved Holding Chamber

• VLBW: Very low birth weight

• VNS: Vagus Nerve Stimulation

• VSD: Ventricular septic defect

• VT: Ventricular Tachycardia

• VUR: Vesicoureteric Reflux

• VZIG: Varicella Zoster Immunoglobulin

• VZV: Varicella Zoster Virus

• WAO: World Allergy Organization

• WASP: Wiskott-Aldrich Syndrome Protein

• WBC: White Blood Cells

• WHO: World Health Organization

• WPW: Wolf- Parkinson-White Syndrome

• XDR: Extensively Drug-Resistant

• YF: Yellow Fever

• ZIG: Zoster Immune Globulin

CURRENT PAEDIATRICS

Abdulgader Bader

MBchB, DCH, MD, CABP, MRCP (London),

CCST (UK), MRCPCH (UK), FRCPCH (UK)

Senior Consultant Paediatric Pulmonologist & Neonatologist, Benghazi Medical Center, Benghazi, Libya

Head of Paediatrics and Medical Director, Mediclinic Al-Jowhara Hospital, Al-Ain, UAE

Honorary Clinical Lecturer, University of Liverpool

Assistant Professor, Faculty of Medicine, Benghazi University and Libyan International Medical University, Benghazi, Libya

NLS Instructor, UK Resuscitation Council

Secretary of Libyan Society of Paediatric Respiratory, Allergy & Clinical Immunology (LSPRACI)

Preface

Welcome to the first edition of The Current Paediatrics book. The book is intended as a practical management guide to the common health problems of paediatrics and is aimed to be used by paediatricians, paediatric nurses, primary health care professionals, junior medical hospital doctors, and medical students. The book is not a text book; it provides a brief synopsis of relevant background information and then a guide to managing common medical and surgical paediatric problems that seen on daily practice.

The edition has been comprehensively revised and updated according to the modern evidence based medicine and international guidelines. The structure of this edition contains the following 25 chapters: The Immunization, Fluid and acid base, Medical emergencies, Cardiovascular disorders, Respiratory disorders, Allergic disorders, Endocrine disorders, Metabolic disorders, Genetic conditions, Gastrointestinal disorders, Hematologic disorders, Neoplastic disorders, Immunodeficiency disorders, Infectious diseases, Renal disorders, Rheumatologic disorders, Neurologic disorders, Psychiatric and Behavioural disorders, Child Protection, Orthopaedic conditions, Ophthalmologic disorders, Ear, Nose and Throat disorders, Gynaecologic disorders, Dermatologic disorders, Surgical disorder. Large parts of the book have been reformatted, with the intension of making the management guidelines clearer and easier to follow.

Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The author of this work has checked with sources believed to be reliable in his efforts to provide information that is complete and generally in accord with the standards accepted at the time of publications. However, in view of the possibility of human error or changes in medical sciences, neither the author nor the publisher warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions of for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. Some of drug doses are included in the text and although every effort has been made to check doses and to ensure consistency between sections, it is possible errors have been missed. We strongly advice that drug doses and product information should be checked, from BNF for children book, before administering drugs to the patients

There are many people to thank in putting together this edition of the Current Paediatrics book. We acknowledge their input and contributions to provide the base upon which this edition is built. Many thanks to Dr Amina El Saleh, Hospital Director, Al Noor Hospitals Group, Al Ain Branch, Al-Ain, UAE and Mr Peter Menelaou, Chief Marketing Officer, Mediclinic Middle East & Al Noor Hospitals Group, UAE for their help and support.

We hope this book will be useful for our Paediatricians Paediatric nurses, primary care providers, junior medical hospital doctors, and medical students and to make their job in paediatrics consistent and exciting

A Bader

January 2018

Dedication

This book is dedicated to the spirit of my father, and also dedicated to my mother, my wife, and my children, for their abundant support, for their patience and understanding, and for their love. Without their support I won’t be able to write and publish this book.

Contents

Chapter 1:   The Immunization

Complications Of Bacille Calmette-Guerin (Bcg)

Hepatitis B Vaccine (Hbv)

Influenza Vaccine

Human Papilloma Virus (Hpv) Vaccine

Pneumococcal Vaccination

Measles Mumps And Rubella (Mmr)

Pertussis

Rota Vaccine

Palivizumab

Chapter 2:   Fluids And Acid Base

Acid Base

Chapter 3:   Medical Emergencies

Causes Of Death In Childhood

Structured Approach To Emergency Paediatrics

Basic Life Support (Bls)

Choking

Airway And Breathing

Airway

Breathing

Cardiac Arrest In Children

The Management Of Cardiac Arrest

The Seriously Ill Child

Recognition Of Potential Respiratory Failure

Recognition Of Potential Circulatory Failure

Recognition Of Potential Central Neurological Failure

Structured Approach To The Seriously Ill Child

Child With Breathing Difficulties

The Child In Shock

The Child With Abnormal Rhythm

The Child With Decreased Conscious Level

The Convulsing Child

Carbon Monoxide Poisoning

The Management Of The Seriously Injured Child

Chest Injury

Abdominal Injury

Head Injury

Child With Burns And Scalds

Child With Injury To The Spine

Stabilization And Transfer

Pain

Triage

Chapter 4:   Cardiovascular Disorders

Assessment Of Patient With Cardiac Problems

Congenital Heart Diseases (Chd) In Neonatal Period

Acyanotic Congenital Heart Diseases

Anomalous Of Left Coronary Artery From Pulmonary Artery

Transient Myocardial Ischaemia

Aortic Stenosis (As)

Atrial Septal Defect (Asd)

Atrioventricular Septal Defects (Avsd)

Coarctation Of The Aorta

Hypoplastic Left Heart Syndrome (Hlhs)

Patent Ductus Arteriosus (Pda)

Pulmonary Stenosis (Ps)

Ventricular Septal Defect (Vsd)

Cyanotic Congenital Heart Diseases

Common Arterial Trunk (Cat)

Ebstein’s Anomaly

Eisenmenger Syndrome

Pulmonary Atresia Or Critical Pulmonary Stenosis (Ps) With Intact Ventricular Septum

Tricuspid Atresia (Ta)

Total Anomaly Pulmonary Venous Connections (Tapvc)

Transverse Of The Great Arteries (Tga)

Tetralogy Of Fallots (Tof)

Cardiac Arrhythmias

Atrial Fibrillation

Atrial Flutter

Complete Atrioventricular Heart Block (Cavb)

Long Qt Syndrome

Paroxysmal Supraventricular Tachycardia (Svt)

Ventricular Extrasystole

Ventricular Tachycardia (Vt)

Cardiomyopathies

Hypertrophic Obstructive Cardiomyopathy (Hocm)

Dilated Cardiomyopathy

Infective Endocarditis

Rheumatic Heart Disease (Rhd)

Pulmonary Arterial Hypertension (Pah)

Chapter 5:   Respiratory Conditions

Examination Of Respiratory System

Lung Development And Anatomy In Early Human Life (Embryology Of Lungs)

Common Respiratory Symptoms

Acute Cough

Chronic Cough

Stridor

Haemoptysis

Recurrent/Persistent Chest Infection

Apnoea

Sleep Apnoea In Children

Obstructive Sleep Apnoea (Osa)

Central Apnoea In Children

Apparent Life Threatening Events (Alte)

Sudden Infant Death Syndrome (Sids)

Respiratory Failure

Chest Wall Deformities

Pectus Excavatum (Pe)

Pectus Carinatum (Pc)

Upper Airway Problems

Choanal Atresia

Laryngeal Cleft

Laryngomalacia

Subglottic Haemangioma

Sub-Glottic Stenosis

Syndromic Airway Problems

Tracheal Stenosis

Tracheobronchomalacia (Tbm)

Vascular Rings

Vocal Cord Palsy

Juvenile Onset Recurrent Respiratory Papillomatosis (Jorrp)

Vocal Cord Dysfunction (Vcd)

Congenital Lung Anomalies

Inherited Surfactant Protein Deficiency

Bronchogenic Cyst

Congenital Cystic Adenomatoid Malformation (Ccam)

Congenital Lobar Emphysema (Cle)

Cystic Hygroma (Ch)

Pulmonary Agenesis

Pulmonary Hypoplasia

Pulmonary Sequestration

Scimitar Syndrome

Disorders Of Small Airways

Acute Asthma

Chronic Asthma

Exercise-Induced Asthma (Eia)

Infantile Wheeze

Post-Infectious Bronchiolitis Obliterans (Bo)

Respiratory Tract Infections

Upper Respiratory Tract Infection (Urti)

The Common Cold (Nasopharyngitis)

Pharyngitis

Peritosilar Abscess

Retropharyngeal Abscess (Ra)

Acute Epiglottitis

Bacterial Tracheitis

Croup Or Laryngotracheobronchitis

Community Acquired Pneumonia (Cap)

Pneumococcal Pneumonia

Staphyloccocal Pneumonia

Chlamydial Pneumonia

Mycoplasma Pneumonia

Severe Acute Respiratory Syndrome (Sars)

Allergic Bronchopulmonary Aspergillosis (Abpa)

Pneumocystis Pneumonia (Pcp)

Acute Bronchiolitis

Acute Bronchitis

Protracted Bacterial Bronchitis (Pbb)

Non-Cystic Fibrosis Bronchiectasis

Cystic Fibrosis (Cf)

Primary Ciliary Dyskinesia (Pcd)

Lung Abscess

Recurrent Aspiration

Foreign Body Aspiration

Pleural Diseases

Pleural Effusion

Chylothorax

Empyema

Pneumothorax

Respiratory Control Disorders

Congenital Central Hypoventilation Syndrome (Cchs)

Other Lung Diseases

Interstitial Lung Disease (Ild)

Acute Lung Injury (Ali) Or Acute Respiratory Distress Syndrome (Ards)

Middle Lobe Syndrome (Mls)

Gastro-Oesophageal Reflux (Gor) & Aspiration Lung Diseases

Respiratory Illness In Child With Severe Neurological Impairment

Chapter 6:   Allergic Disorders

Introduction To Allergic Disorders

Physiology Of Allergy

Pathogenesis Hypothesis For Allergy

Pathogenesis Of Allergy

Diagnosis Of Allergy

Management Of Allergy

Prevention Of Allergy

Food Allergy

Ige- Mediated Food Allergy

Non-Ige Mediated Food Allergy

Food Protein-Induced Enterocolitis (Fpies)

Cow’s Milk Protein Allergy (Cmpa)

Ige- Mediated Milk Allergy

Allergic Eosinophilic Gastroenteropathies

Non-Ige- Mediated Cow’s Milk Allergy

Food Protein-Induced Enterocolitis (Fpies)

Cmp-Induced Proctocolitis

Cmp-Induced Enteropathy Syndrome

Allergic Dysmotility

Egg Allergy

(Type-1 Ige-Mediated Allergy)

Peanut Allergy

Tree Nuts Allergy

Sesame Seed Allergies

Wheat Allergy

Oral Allergy Syndrome (Oas)

Pollen-Food Syndrome (Pfs)

Plant Food Allergens

Drug Allergy

Latex Allergy

Venom Allergy

Allergic Rhinitis (Ar)

Anaphylaxis

Urticaria

Specific Immunotherapy (Sit)

Sublingual Immunotherapy (Slit)

Subcutaneous Immunotherapy (Scit)

Chapter 7:   Endocrine Disorders

Disorders Of Adrenal Glands

Adrenal Insufficiency

Addison’s Disease

Adrenal Haemorrhage

Congenital Adrenal Hyperplasia (Cah)

Congenital Adrenal Hypoplasia

Cushing’s Syndrome

Hyperaldosteronism

Pseudohypoaldosteronism

Diabetes Mellitus

Type 1 Diabetes Mellitus (Tid)

Maturity Onset Diabetes Of The Young (Mody)

Type 2 Diabetes Mellitus (T2d)

Neonatal Diabetes

Diabetic Ketoacidosis (Dka)

Acute Cerebral Oedema (Ace)

Surgery And Diabetic Child

Hypoglycaemia

Hypoglycaemia Beyond The Neonatal Period

Hypoglycaemia In Diabetes

Ketotic Hypoglycaemia

Hyperinsulinemia

Disorders Of Puberty And Gonads

Delayed Puberty

Arrested Puberty

Constitutional Delay Of Growth & Adolescence (Cdga)

Social Deprivation

Klinefelter Syndrome

Precocious Puberty

Ovitestis

Thyroid Gland Disorders

Hypothyroidism

Hashimotos (Lymphocytic, Autoimmune) Thyroiditis

Parathyroid Gland And Calcium Disorders

Hypoparathyroidism

Pseudohypoparathyroidism

Primary Hyperparathyroidism

Hypercalcaemia In Children

Idiopathic Hypercalcaemia Of Infancy (Lightwood Syndrome)

Familial Hypocalciuric Hypercalcaemia (Fhh) Or Familial Benign Hypercalcaemia

Disorders Of Pituitary Gland

Septo-Optic Dysplasia

Growth Hormone (Gh) Deficiency

Central Diabetes Insipidus

Syndrome Of Inappropriate Adh Secreation (Siadh)

Chapter 8:   Metabolic Conditions

Classification Of Inherited Metabolic Diseases (Imd)

Phenylketonuria (Pku)

Tyrosinemia

Maple Syrup Urine Disease

Homocystinuria

Cystinosis

Cystinuria

Albinism

Hartnup Disease

Organic Acidemia

Urea Cycle Disorders

Reye Syndrome

Galactosemia

Hereditary Fructose Intolerance

Glycogen Storage Disease

Hyperlipidaemia

Secondary Hyperlipidaemia

Hereditary Hyperlipidaemia

A Beta-Lipoproteinemia

Lipidosis

Fatty Acid Oxidation Defects

Long-Chain Fatty Acyl Coa Dehydrogenase (Lcad) And Medium-Chain Fatty Acyl Coa Dehydrogenase (Mcad) Deficiency

Wilson’s Disease

Mucopolysaccharidosis

Disorders Of Carnitine Metabolism

Porphyria

Erythropoietic Porphyria

Hepatic Porphyria

Erythrohepatic Porphyria

Chapter 9:   Genetic Conditions

Craniosynostosis

Pfeiffer Syndrome

Apert Syndrome

Crouzon Syndrome

Syndromes With Micrognathia

Pierre Robin Sequence

Goldenhar (Oculo-Auricular Vertebral) Syndrome

Stickler Syndrome

Treacher–Collins Syndrome (Tcs)

Di George Syndrome

Congenital Absence Of Fibula

Angelman Syndrome

Charge Association

Downs Syndrome

Edwards Syndrome (Trisomy 18)

Fragile X Syndrome

Klinefelter’s Syndrome

Marfan Syndrome

Noonan Syndrome

Prader-Willi Syndrome (Pws)

Silver–Russell Syndrome (Srs)

Sotos Syndrome (Cerebral Gigantism)

Turner Syndrome

Williams-Beuren Syndrome

Chapter 10:   Gastrointestinal Disorders

Common Gastrointestinal Symptoms

Acute Gastroenteritis (Age) In Children

Chronic Diarrhoea

Vomiting In Children

Chronic Constipation In Children

Infantile Colic

Recurrent Abdominal Pain (Rap)

Failure To Thrive (Ftt)

Hypercarotenaemia

Persistent Or Extreme Picky Eating

(Avoidant/Restrictive Food Intake Disorder ‘Arfid’)

Malabsorption

Coeliac Disease (Cd)

Shwachman-Diamond Syndrome

Acrodermatitis Enteropathica

Intestinal Lymphangiectasia

Abetalipoproteinemia

Inflammatory Bowel Disease (Ibd)

Gastro-Oesophageal Reflux (Gor)

Helicobacter Pylori

Cyclical Vomiting Syndrome (Cvs)

Lactose Intolerance

Toddler Diarrhoea

Irritable Bowel Syndrome (Ibs)

Pancreatitis

Portal Hypertension

Chapter 11:   Haematologic Disorders

Anaemia

Fanconi Anaemia

Diamond-Blackfan Syndrome (Pure Red Cell Aplasia)

Acquired Aplastic Anaemia

Iron Deficiency Anaemia

Megaloblastic Anaemia Of Infancy

Juvenile Pernicious Anaemia

Hereditary Spherocytosis

Glucose-6-Phosphate Dehydrogenase Deficiency

Pyruvate Kinase Deficiency

Sickle Cell Disease

Sickle Cell Anaemia

Sickle Cell Trait

Sickle B Thalassemia

Sickle C Disease

Thalassemia

Α-Thalassemia

Β-Thalassemia Major

Β- Thalassemia Trait (Thalassemia Minor)

Β-Thalassemia Intermedia

Idiopathic Autoimmune Haemolytic Anaemia (Aiha)

Paroxysmal Nocturnal Haemoglobinuria (Pnh)

Haemolytic Transfusion Reaction

Polycythaemia

Disorders Of White Blood Cells

Bleeding Disorders

Platelets Disorders

Idiopathic Thrombocytopenic Purpura (Itp)

Coagulation Disorders

Von Willebrand Disease

Haemophilia A (Factor Viii Deficiency)

Christmas Disease (Haemophilia B, Factor Ix Deficiency)

Factor Xi Deficiency

Factor Xii Deficiency (Hageman Factor)

Factor Xiii Deficiency

Afibrinogenemia & Dysfibrinogenemia

Thrombosis

Acquired Coagulopathies Vitamin K Deficiency

Coagulation Disorders In Liver Disease

Disseminated Intravascular Coagulation (Dic)

Chapter 12:   Neoplastic Disorders

Childhood Cancer

Leukaemia

Acute Lymphoblastic Leukaemia

Acute Myeloblastic Leukaemia

Adult-Type Chronic Myeloid Leukaemia

Juvenile-Type Chronic Myeloid Leukaemia

Neuroblastoma

Non-Hodgkin’s Lymphoma (Nhl)

Hodgkin’s Disease (Hd)

Wilms Tumour

Hepatoblastoma

Bone Tumour

Brain Tumour

Craniopharyngioma

Langerhans Cell Histiocytosis

Retinoblastoma (Rb)

Tumour Lysis Syndrome

Chapter 13   Immunodeficiency Disorders

Primary Immune-Deficiency

Chronic Mucocutaneous Candidiasis

Graft-Versus-Host Disease (Gvhd)

Severe Combined Immune Deficiency (Scid)

Wiskott-Aldrich Syndrome

X-Linked Agammaglobulinemia

Iga And Igg2 Deficiency

Transient Hypogamaglobulinemia Of Infancy

Chronic Granulomatous Disease (Cgd)

Chediak-Higashi Syndrome

Hereditary Angioneurotic Oedema (Hae)

Chapter 14:   Infectious Diseases

Common Infectious Symptoms

Pyrexia Of Unknown Origin

Purpura Fulminans

Cellulitis

Necrotizing Fascitis

Impetigo Contagiosa

Bacterial Meningitis

Herpangina

Streptococcal Infections

Scarlet Fever

Ecthyma

Erysipelas

Streptococcal Toxic Shock Syndrome (Strep-Tss)

Staphylococcal Infections

Staphylococcal Scalded Skin Syndrome (Ssss)

Toxic Epidermal Necrolysis Or Lyell’s Diseases

Staphylococcal Toxic Shock Syndrome (Staph-Tss)

Bullous Impetigo

Infant Botulism

Lyme Disease

Invasive Meningococcal Disease (Imd)

Pneumococcal Disease

Invasive Pneumococcal Disease (Ipd)

Salmonellosis

Typhoid Fever

Pertussis (Whooping Cough)

Tuberculosis (Tb)

Tb During Pregnancy

Multidrug-Resistant Tuberculosis (Mdr-Tb)

Rocky Mountain Spotted Fever (Rmsf)

Viral Infections

Acquired Cytomegalovirus (Cmv)

Herpes Zoster (Shingles)

Varicella-Zoster (Chickenpox)

Herpes Simplex Viruses (Hsv)

Adenovirus

Influenza

Enteroviral Infections

Hand-Foot-Mouth Disease

Viral Hepatitis

Hepatitis A Virus (Hav)

Hepatitis C Virus (Hcv

Hepatitis D Virus (Hdv)

Hepatitis E Virus (Hev)

Hepatitis B Virus (Hbv)

Measles (Rubeola)

Rubella (German Measles)

Erythema Infectiosum (Fifth Disease)

Roseola Infantum (Sixth Disease)

Glandular Fever (Infectious Mononucleosis)

Mumps

Human Immunodeficiency Virus (Hiv)

Dengue Viral Infection

Molluscum Contagiosum

Warts

Fungal Infections

Candidiasis (Moniliasis)

Vaginal Candidiasis

Mucormycosis

Tinea Capitis (Ringworm Of Scalp)

Tinea Corporis

Tinea Pedis (Athlete’s Foot)

Tinea (Pityriasis) Versicolor

Parasitic Infections

Malaria

Giardia Lamblia (Giardiasis)

Scabies

Threadworms (Enterobius Vermicularis)

Head Lice Infestation (Pediculosis Capitis)

Toxocariasis

Schistosomiasis (Bilharzia)

Cryptosporidium Parvum - Cryptosporidiosis

Chapter 15:   Renal Disorders

Haematuria And Proteinuria

Hypercalciuria

Urinary Tract Infection (Uti)

Nephrotic Syndrome (Ns)

Secondary Nephrotic Syndrome

Congenital Nephrotic Syndrome (Finnish Type)

Post Streptococcal Glomerulonephritis

Mesangial Iga Nephropathy (Berger’s Disease)

Alport Syndrome

Haemolytic–Uremic Syndrome (Hus)

Acute Kidney Injury (Aki)

Chronic Renal Insufficiency (Cri)

Hypertension (Ht)

Renal Artery Stenosis

Renal Vein Thrombosis

Renal Tubular Disorders

Distal Renal Tubular Acidosis (Type 1 Rta)

Proximal Renal Tubular Acidosis (Type 2 Rta)

Fanconi Syndrome

Bartter’s Syndrome

Gitelman Syndrome (Gs)

Nephrogenic Diabetes Insipidus

Chapter 16:   Rheumatologic Disorders

Assessment Of Child With Joints Problems

Acute Limping In Children

Juvenile Idiopathic Arthritis (Jia)

Systemic Lupus Erythematosus (Sle)

Juvenile Dermatomyositis

Acute Rheumatic Fever (Arf)

Henoch-Schonlein Purpura (Hsp)

Kawasaki Disease (Kd)

Chapter 17:   Neurologic Disorders

Central Nervous System Examination

Common Central Nervous System Symptoms

Chronic Headache

Migraine

Syncope And Dizziness

Encephalopathy In Children

Disordered Development

Learning Difficulty (Ld)

The Floppy Infant

Ataxia

Epilepsy

Generalized Tonic-Clonic Seizures (Gtcs)

Absence (Petit-Mal) Seizures

Myoclonic And Drop Attacks

Juvenile Myoclonic Epilepsy

Infantile Spasms (West Syndrome)

Focal Seizures

Benign Partial Epilepsy Of Childhood (Benign Rolandic Epilepsy)

Febrile Convulsions

Convulsive Status Epilepticus (Cse)

Minor Epilepticus Status

Cerebral Palsy (Cp)

Neurodegenerative Disorders

Juvenile Cerebroretinal Degeneration (Ceroid Lipofuscinosis)

Leigh’s Disease Subacute Necrotizing Encephalopathy (Sne)

Rett Syndrome

Subacute Sclerotic Panencephalitis (Sspe)

Acute Disseminated Encephalomyelitis (Adem)

Neurocutaneous Disorders

Neurofibromatosis (Nf)

Neurofibromatosis Type 1 (Nfi)

Segmental Or Mosaic Nfi

Neurofibromatosis Type 2 (Nf2)

Other Form Of Neurofibromatosis

Tuberous Sclerosis (Ts)

Sturge-Weber Syndrome

Cerebellar Disorders

Ataxia Telangiectasia (At)

Friedreich’s Ataxia

Arnold-Chiari Malformation (Acm)

Joubert Syndrome

Cns Infections

Encephalitis

Brain Abscess

Infected Ventriculoperitoneal Shunt

Disorders Of Raised Intracranial Pressure (Icp)

Benign Intracranial Hypertension

Cerebral Oedema

Dural Sinus Thrombosis

Subdural Haematoma Or Effusion

Hydrocephalous

Sleep Disorders

Sleep Disturbance

Narcolepsy

Night Terrors

Spinal Cord Disorders

Meningomyelocele

Transverse Myelitis

Disorders Of Cranial Nerves

Optic Neuritis

Oculomotor Nerve Palsy

Facial Nerve Palsy (Fnp)

Disorders Of Peripheral Nerves

Spinal Muscular Atrophy (Werdnig-Hoffman Disease)

Chronic Spinal Muscular Atrophy

Guillain - Barre Syndrome (Gbs)

Peroneal Muscular Atrophy (Charcot-Marie-Tooth Disease)

Muscles Disorders

Congenital Muscular Dystrophy

Duchenne Muscular Dystrophy

Becker Muscular Dystrophy

Congenital Myotonic Dystrophy

Congenital Myopathies

Juvenile Myasthenia Gravis

Hyperkalemic Periodic Paralysis

Chapter 18:   Psychiatric And Behavioural Disorders

Attention Deficit Hyperactivity Disorder (Adhd)

Autism Spectrum Disorder (Asd)

Bedwetting (Enuresis)

Chronic Primary Polydipsia

Tourette Syndrome

Chapter 19:   Child Protection

Child Abuse (Non Accidental Injuries)

Bruising

Burns

Oral Injuries

Bite Injuries

Abdominal Injuries

Poisoning

Shaken Impact (Baby) Syndrome

Skeletal Injuries (Nasi)

Sexual Abuse

Chapter 20:   Orthopaedic Conditions

Achondroplasia

Developmental Dysplasia Of Hip (Ddh)

Fibrodysplasia Ossificans Progressiva (Fop)

Transient Synovitis Of The Hip

Acute Septic Arthritis (Asa)

Acute Osteomyelitis

Chronic Non-Bacterial Osteomyelitis (Cno)

Perthes’ Disease

Slipped Upper Femoral Epiphysis (Sufe)

Vitamin D Deficiency

Vitamin D Deficiency Rickets

Idiopathic/Habitual Toe Walking (Itw)

Discitis

Adolescent Idiopathic Scoliosis (Ais)

Neuromuscular Spinal Deformity In Disabled Children

Baker’s (Popliteal) Cyst

Chapter 21:   Ophthalmologic Disorders

Red Eye

Bacterial Conjunctivitis

Viral Conjunctivitis

Allergic Conjunctivitis

Stye

Chalazion

Orbital Cellulitis

Periorbital Cellulitis

Cataract

Congenital Glaucoma

Chapter 22:   Ear, Nose And Throat Conditions

Enlarged Tonsils And Adenoids

Acute Otitis Media (Aom)

Otitis Media With Effusion (Ome)

Acute Mastoiditis

Acute Sinusitis

Epistaxis

Chapter 23:   Gynecologic Disorders

Hymenal Tag

Labial Adhesions

Vaginal Bleeding

Vaginal Discharge

Vulvar Irritation

Vulvovaginitis

Chapter 24:   Dermatologic Disorders

Alopecia

Bullous Dermatoses

Keratinization Disorders

Acanthiosis Nigricans

Confluent And Reticulated Papillomatosis (Carp)

Eczematous Reactions

Seborrheic Dermatitis (Cradle Cap, Dandruff)

Napkin Dermatitis (Diaper Dermatitis, Diaper Rash)

Exfoliative Dermatitis (Generalized Erythroderma)

Atopic Eczema (Atopic Dermatitis)

Cmp Sensitive Eczema

Eczema Herpeticum (Eh)

Hypersensitivity Syndromes

Erythema Multiforme (Em)

Stevens-Johnson Syndrome (Erythema Multiforme Major)

Erythema Nodosum

Infantile Haemangioma (Ih)

Lichen Disorders

Lichen Nitidus (Ln)

Lichen Planus (Lp)

Lichen Sclerosus

Lichen Striatus (Ls)

Papular Urticaria

Pityriasis (Tinea) Versicolor

Gianotti-Crosti Syndrome (Papular Acrodermatitis Of Childhood)

Chapter 25:   Surgical Disorders

Surgical Problems Of The Gastrointestinal Tract

Congenital Intestinal Atresia & / Or Stenosis

Malrotation/Volvulus

Intestinal Duplication

Persistent Vitello-Intestinal & Meckel’s Diverticulum

Hirschsprung’s Disease

Intestinal Neuronal Dysplasia

Meconium Ileus

Milk Plug Obstruction

Biliary Atresia / Neonatal Hepatitis

Infantile Hypertrophic Pyloric Stenosis (Ihps)

Intussusception

Acute Appendicitis

Srgical Problems Of Chest

Tracheo-Oesophageal Fistula (Tof)

Oesophageal Perforation

Congenital Diaphragmatic Hernia

Surgical Problems Of Urogenital Tract

Pelviutreteric Junction Obstruction (Puj)

Non-Refluxing Obstructed Megaureter

Multicystic Dysplastic Kidney

Primary Vesicoureteric Reflux

Posterior Urethral Valve (Puv)

Neuropathic Bladder

Male Circumcision

Undescended Testis

Varicocele

CHAPTER 1

THE IMMUNIZATION

ROUTINE CHILDHOOD IMMUNIZATION PROGRAMME FROM JUNE 2006 IN THE UK

ROUTINE CHILDHOOD IMMUNIZATION PROGRAMME IN THE GULF REGION

IMMUNISATION SCHEDULE FOR LIBYA

HBV: Hepatitis B vaccine

OPV: Oral Polio Vaccine

IPV: Injection polio vaccine

HIB: Haemophilus Influenza Type B

PCV: Pneumococcal Vaccine

Men: Meningitis A,C,Y, W135

MMR: Measles, Mumps, Rubella

HPV: Human Papilloma Virus

DTaP: Diphtheria, Tetanus, Acelluar Pertussis

Penta: DTaP + HiB + HBV

Hexa: DTaP + HiB + HBV + IPV

Tetra: DTaP + HiB

Contraindication to Immunization

• Febrile illness / acutely unwell

• Altered immunity (live vaccine)

• Evolving neurological disease

• Confirmed anaphylactic reaction following immunization with the same vaccine

• Anaphylactic reaction to one component of the vaccine

NB

• If live vaccines are given simultaneously, then each vaccine virus will begin to replicate and an appropriate immune response is made to each vaccine. After a live vaccine is given, natural interferon is produced in response to that vaccine. If a second live vaccine is given during this response, the interferon may prevent replication of the second vaccine virus.

• This may attenuate the response to the second vaccine. Based on evidence that MMR vaccine can lead to an attenuation of the varicella vaccine response (Mullooly and Black, 2001), the recommended interval between live vaccines is currently four weeks. For this reason, if live vaccines cannot be administered simultaneously, a four-week interval is recommended.

The 2013 Recommendations by the American Academy of Paediatrics (AAP)

• Administration of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine to adolescents and pregnant women. This should improve protection of newborns from the morbidity and potential mortality of pertussis before they can safely be vaccinated with DTaP

• Rotavirus vaccine: A footnote clarifies the number of doses for RV1 and RV5.

• Haemophilus influenza type b vaccine: Unvaccinated children at least 15 months of age should receive only 1 dose of this vaccine.

• Pneumococcal vaccine: The 13-valent pneumococcal conjugate vaccine is indicated in children aged 24 to 71 months and indications for use of the 23-valent pneumococcal polysaccharide vaccine in children at least 2 years of age.

• Meningococcal vaccine: Vaccination of children aged 2 months through 10 years with high-risk conditions.

COMPLICATIONS OF BACILLE CALMETTE-GUERIN (BCG)

Introduction

• Adverse reactions to BCG vaccination are rare, provided that correct immunisation techniques are used and that those to be vaccinated are properly selected.

• Bacille Calmette-Guérin (BCG) is a live attenuated vaccine

• BCG is usually given to children in the United Kingdom (UK) between the ages of 10 and 14 years and neonates at high risk groups

• Intradermal injection, using a vaccine that contains 8-26 million colony forming units (cfu) in each 10 dose vial - that is, 0.8-2.6 million cfu in each standard 0.1 ml dose.

• Infants may, alternatively, be vaccinated percutaneously by a multipuncture technique, using a vaccine that contains 50 to 250 million cfu in each vial.

• BCG has also been used as an immunotherapeutic agent in patients with various forms of cancer. In the treatment of superficial cancer of the bladder by intravesical instillation.

• Vaccine should be given only to those who are shown to be tuberculin negative (Heaf grades 0 and 1 and Mantoux responses of 0-4 mm), although infants up to 3 months of age may be vaccinated without prior tuberculin testing.

• People with a history of BCG vaccination should be revaccinated only if they are tuberculin negative and have no characteristic BCG scar.

NB

• Effectiveness of BCG is > 70 % and persisting for 15 years.

• BCG offer protection against Leprosy.

• Interval of at least 3 weeks should be allowed between the administration of a live vaccine and BCG.

Incidence

• Local complications: Occur at a rate of 0.1 to 0.5 per 1000 vaccinations

• Serious disseminated disease: Develops in < 1: 1000,0007

Mechanisms

• Faulty technique, including the accidental intracutaneous injection

• Poor selection of subjects for vaccination.

Indications

• TT < 6 mm or Heaf grade 0 and 1

• Children with a high-risk of exposure to TB: Should be vaccinated in the neonatal period

• Students, including those in teacher training colleges

• Health Service Workers

NB

• Neonates and infants (< 3 months) who had no contact with TB may offered BCG without prior TST.

Contraindications

• Malignancy

• Corticosteroid treatment

• Fever

• Pregnancy

• Generalised septic skin conditions

• Immunosuppressive disorders

• Risk of having HIV infection

• Infants born to mothers known or suspected to be HIV infected, unless the infants are subsequently confirmed to be HIV negative.

• In countries with a low incidence (< 40/100 000)

• TST positive and Heaf grade 2 or more

• Generalized infective skin conditions (site free from lesions should be chosen for vaccination)

Complications of BCG Vaccination

Infectious Complications

Localised Complications

• Hypertrophic or keloid scar, if given at sites other than insertion of deltoid.

• Abscesses and ulcers at the injection site

• Localised lymphadenopathy and suppurative lymphadenitis in the drainage area of the vaccinated site.

• Usually present between one and five months after vaccination

• The great majority resolved spontaneously and only eight (0.02%) proceeded to suppuration and discharge.

Disseminated Disease: Usually occurs in people with impaired immunity

• Osteitis

• Disseminated disease (BCG-osis.).

• Arthritis

• Responds to antituberculosis chemotherapy.

Non-Infectious Complications

Localised Complications

• keloid scarring (18.2%). The risk of such scarring is minimised by giving the injection in the skin overlying the insertion of the deltoid muscle.

• Hypersensitivity reactions

Disseminated Disease

• Erythema nodosum

• Phlyctenular conjunctivitis.

• Generalised, life threatening hypersensitivity reactions

Management

Treatment depends on the nature (infectious or non-infectious) of the complication, its severity, and the nature of any underlying causative factor.

Localised Complications

• Material, for example, swabs or aspirated pus, should be obtained from abscesses and ulcers at the site of immunisation to confirm that BCG is the cause or to identify other organisms that occasionally cause such reactions - for example, staphylococci or environmental mycobacteria

• Abscesses at the injection site: Drainage, needle aspiration, topical or systemic isoniazid, or systemic erythromycin. For 6 weeks

• Lymphadenopathy: Responds poorly to antimicrobial treatment and surgery may be needed for suppurating or discharging lesions to hasten recovery and give a good cosmetic result.

Distant Complications

• Disseminated disease is treated in a similar manner as tuberculosis due to virulent M. bovis - that is, with rifampicin and isoniazid and a third drug selected from ethambutol, ethionamide, and streptomycin. Pyrazinamide is not used as, in common with M. bovis, BCG is naturally resistant to this agent.

• Continue treatment for longer than the usual six-month period in immunocompromised patients

• Treatment should be conducted in close collaboration with a chest physician experienced in the treatment of tuberculosis.

Prognosis

Localised Complications

• Most are either self-limiting or respond to straightforward management.

Distant Complications

• The mortality in such immunocompromised patients is high, despite treatment.

References

1. Department of Health, Welsh Office, Scottish Office Department of Health, DHSS (Northern Ireland). Immunisation against infectious disease - 1996 Edward Jenner bicentenary edition. London: HMSO, 1996.

2. Lamm DL. Complications of bacillus Calmette-Guérin immunotherapy. Urol Clin North Am 1992; 19: 565-72.

3. Williams DE. Mycobacterium bovis BCG infection in humans. In: Thoen CO, Steele JH, editors. Mycobacterium bovis infection in animals and humans. Ames: Iowa State University Press, 1995: 47-61.

4. Dalton SJ, Haeney MR, Patel L, David TJ. Exacerbation of atopic dermatitis after bacillus Calmette-Guérin vaccination. J R Soc Med 1998; 91: 133-4.

5. World Health Organization. HIV and routine childhood immunization. Wkly Epidemiol Rec 1987; 62: 297-9.

6. Subcommittee of the joint Tuberculosis Committee of the British Thoracic Society. Guidelines on the management of tuberculosis and HIV infections in the United Kingdom. BMJ 1992; 304: 1231-3.

7. Lotte A, Wasz-Höckert O, Poisson N, Dumitrescu N, Verron M, Couvet E. BCG complications. Advances in Tuberculosis Research 1984; 21: 107-93.

8. de Souza GRM, Sant. Anna CC, Lapa e Silva JR, Mano DB, Bethlem NM. Intradermal BCG vaccination complications - analysis of 51 cases. Tubercle 1983; 64: 23-7.

9. Goldman KP. Treatment of local complications of BCG vaccination. Tubercle 1985; 66: 158-9.

10. Mori T, Yamauchi Y, Shiozawa K. Lymph node swelling due to bacille Calmette-Guérin vaccination with multipuncture method. Tubercle and Lung Disease 1996; 77: 269-73.

11. Miles MM, Shaw RJ. Effect of inadvertent intradermal administration of high dose percutaneous BCG vaccine. BMJ 1996; 312: 1205.

12. Puliyel JM, Hughes A, Chiswick ML, Mughal MZ,. Adverse local reactions from accidental BCG overdose in infants. BMJ 1996; 313: 528-9.

13. Murphy PM, Mayers DL, Brock NF, Wagner KF. Cure of bacilles Calmette-Guérin vaccination abscesses with erythromycin. Rev Infect Dis 1989; 11: 335-7.

14. Singh G, Singh M. Erythromycin for BCG cold abscess. Lancet 1984; 2: 979.

15. Hanley SP, Gumb J, MacFarlane JT. Comparison of erythromycin and isoniazid in treatment of adverse reactions to BCG vaccination. BMJ 1985; 290: 970.

16. Hengster P, Solder B, Fille M, Menardi G. Surgical treatment of bacillus Calmette-Guérin lymphadenitis. World J Surg 1997; 21: 520-3.

17. Kroger L, Korppi M, Brander E, Kroger H, Wasz-Hockert O, Backman A, et al. Osteitis caused by bacille Calmette- Guérin vaccination: a retrospective analysis of 222 cases. J Infect Dis 1995; 172: 574-6.

18. Casanova JL, Blanche S, Emile JF, Jouanguy E, Lamhamedi S, Altare F, et al. Idiopathic disseminated bacillus Calmette- Guérin infection: a French national retrospective study. Pediatrics 1996; 98: 774-8.

19. Talbot EA, Perkins MD, Silva SFM, Frothingham R. Disseminated bacille Calmette-Guérin disease after vaccination: case report and review. Clin Infect Dis 1997; 24: 1139-46.

20. O. Brien KL, Ruff AJ, Louis MA, Desormeaux J, Joseph DJ, McBrien M, et al. Bacillus Calmette-Guérin complications in children born to HIV-1-infected women with a review of the literature. Pediatrics 1995; 95: 414-8.

21. Besnard M, Sauvion S, Offredo C, Gaudelus J, Gaillard JL, Veber F, et al. Bacillus Calmette-Guérin infection after vaccination of human immunodeficiency virus-infected children. Pediatr Infect Dis J 1993; 12: 993-7.

22. DeHaven JI, Traynellis C, Riggs DR, Ting E, Lamm DL. Antibiotic and steroid therapy of massive bacillus Calmette- Guérin toxicity. J Urol 1992; 147: 738-42.

23. Leebeek FW, Ouwendijk RJ, Kolk AH, Meek JC, Nienhuis JE, Dingemans-Dumas AM. Granulomatous hepatitis caused by bacillus Calmette-Guérin (BCG) infection after BCG bladder instillation. Gut 1996; 38: 616-8.

24. Koukol SC, DeHaven JL, Riggs DR, Lamm DL. Drug therapy of bacillus Calmette-Guérin sepsis. Urol Res 1995; 22: 373-6.

HEPATITIS B VACCINE (HBV)

• Universal hepatitis B vaccination programs are ongoing in endemic areas.

• The HBV consists of recombinant hepatitis B surface antigen (HBsAg) produced in yeast.

• A series of 3 injections may achieve HBsAb levels greater than 10 million IU/mL in approximately 95% of people vaccinated.

• Vaccination with a single dose must be repeated every 5-10 years.

• All newborns must be vaccinated against hepatitis B.

• For infants born to mothers with active hepatitis B, a passive-active (immunoglobulin [HBIG] and vaccination) approach is recommended.

• Healthcare workers or people who have had a needle-stick accident from a patient with active hepatitis B infection must receive the active-passive immunization approach (HBIG and the first dose of the vaccine at the same time), and these individuals must be monitored with blood tests.

• Current guidelines recommend all previously unvaccinated adults aged 19 through 59 years with diabetes mellitus (type 1 and type 2) be vaccinated against hepatitis B as soon as possible after a diagnosis of diabetes is made

• Low response rates have been associated with obesity, smoking, immunosuppression, and advanced age.

• Approximately 25-50% of persons who initially do not have a vaccine response will show a response to 1 additional vaccine dose, and 50-75% of persons will have a response to a second 3-dose series.

• A combined hepatitis A virus (HAV) and hepatitis B vaccine is licensed in many countries and offers the advantage of protection against both of these diseases at the same time.

NB

• Delay in vaccination does not require restarting the series

• Postimmunization serologic screening recommended for infants of HBsAg positive mother at 1 year of age (5% become carrier)

• Protection from vaccine last for 5 years in children and 9 years in adults

References

1. Olde C, Garcia M. Hepatitis B vaccine as a cause of false positive hepatitis B surface antigen. J CANNT. 1998;8(4):20-1.

INFLUENZA VACCINE

Indications

• All individuals aged >65 years

• Health care workers

• All individuals aged 6 months in high-risk groups (e.g. chronic respiratory disease including asthma)

NB

• All children aged 2 years in England, around 650 000 in total, will be offered a nasal flu vaccine from September 2013 as part of new vaccines schedules

Production of Vaccine

• Influenza vaccines are derived from the extra-embryonic fluid of chicken embryos inoculated with specific types of influenza virus. The vaccines typically contain measurable quantities of residual egg white protein (OVA).

Adverse Effects

• Risk of allergic reaction to influenza vaccine in egg-allergic individuals. Immediate allergic reactions, including anaphylaxis have been reported in patients with egg allergy after influenza vaccination.

Contraindications

• Patients who have had anaphylaxis to egg. A new study offers more reassurance that kids with egg allergies can be safely vaccinated against the virus (J Allergy Clin Immunol 2012).

• Acute illness

• Anaphylactic reaction to a previous dose of the vaccine

NB

• All children ages 6 months to 13years who receive a seasonal influenza vaccine for the first time should receive 2 doses at least 1 month apart.

• Children aged > 13 years are given a single dose of vaccine annually

• Vaccine is not recommended in children < 6 months

• Children who have received seasonal influenza vaccine previously but who have not received 2 or more total doses since July 2010 should also receive 2 doses.

• Children who have received 2 or more total doses of seasonal vaccine since July 2010 should receive 1 dose."

• Egg-allergic kids should get the flu shot from a doctor who can recognize and, if needed, treat a severe reaction. Monitor egg-allergic kids for 30 minutes after the injecion

• The influenza vaccine for the 2012-2013 season will guard against the pandemic A (H1N1) virus from 2009.

• The 3 viral strains (trivalent seasonal flu vaccine) are made of 1 B strain and 2 A strains, with one in the A(H1N1) camp and the other in the A(H3N2) camp

• Every year, the experts identify influenza strains most likely to circulate in the upcoming influenza season by scrutinizing current virus samples and global disease patterns.

HUMAN PAPILLOMA VIRUS (HPV) VACCINE

• The scientists have called for boys to be given the cervical cancer vaccine as well as girls,

• The vaccine has been given to 12 and 13-year-old girls since 2008 and protects against human papilloma virus, which is behind most cases of cervical cancer.

• HPV has been blamed for many other tumours, prompting Stanley to suggest boys receive it as well. She claimed not protecting boys against a host of cancers such as tumours of the tongue, tonsils, head and neck would be unethical and unfair.

PNEUMOCOCCAL VACCINATION

• Vaccination against pneumococcal infection was introduced into the UK routine childhood immunisation programme in 2006 with 7-valent pneumococcal conjugate vaccine (PCV 7) or Prevenar-7 against seven pneumococcal serotypes (4, 6B, 9V, 14, 18C, 19F and 23F).

• In the spring of 2010 we will replace this vaccine with `Prevenar 13? Which protects against six additional serotypes (1, 3, 5, 6A, 7F and 19A in addition to the seven serotypes against which Prevenar-7 protects).

• Given to all children via the routine childhood immunisation programme at 2, 4 and 13 months of age. They should receive one dose of the 23-valent pneumococcal polysaccharide vaccine (PPV) after their second birth day

• Pneumococcal disease continues to be a problem despite these measures.

Supplemental Dose of PCV13

• A single supplemental dose of the 13-valent pneumococcal conjugate vaccine (PCV13) is recommended for healthy children aged 14 through 59 months who were fully vaccinated with the 7-valent pneumococcal conjugate vaccine.

• Unimmunised children between 12 months and 5 years of age should receive 2 doses of PCV separated by 2 months and a single dose of PPV after their second and at least 2 months after their last dose of PCV

• Unimmunised children over 5 years of age should receive one doses of PPV only

MEASLES MUMPS AND RUBELLA (MMR)

There are many reasons to use combination vaccines, including

• Improved practice efficiency

• Improved immunization coverage rates

• Reduced trauma to patients

• Does not seem to pose risk for febrile seizure or febrile illness risk

PERTUSSIS

Prevention through immunization remains the best defence in the fight against pertussis. CDC recommendations for vaccination are as follows:

• DTaP vaccine: Recommended at the ages of 2, 4, 6, and 15-18 months and at age 4-6 years; it is not recommended for children aged 7 years or older

• Tdap vaccine: Recommended for children aged 7-10 years who are not fully vaccinated; as a single dose for adolescents 11-18 years of age; for any adult 19 years of age or older; and for pregnant woman regardless of vaccination history, including repeat vaccinations in subsequent pregnancies

• Teenagers who received four doses of the newer acellular pertussis vaccines were nearly six times as likely to receive a diagnosis of pertussis during a recent outbreak in California than were those who received doses of the older, whole cell preparation

ROTA VACCINE

• There is an increased risk of intussusception after rotavirus vaccination.

• The benefits of vaccination outweigh risks, at least in countries with high infant mortality

Contraindications

• A history of intussusceptions

References

1. Patel MM, Lopez-Collada VR, Bulhoes MM, et al. Intussusception risk and health benefits of rotavirus vaccination in Mexico and Brazil. N Engl J Med 2011;364:2283-2292

2. Farrington CP. Relative incidence estimation from case series for vaccine safety evaluation. Biometrics 1995;51:228-235

3. Murphy TV, Gargiullo PM, Massoudi MS, et al. Intussusception among infants given an oral rotavirus vaccine. N Engl J Med 2001;344:564-572

4. Greenberg HB. Rotavirus vaccination and intussusceptions — act two. N Engl J Med 2011;364:2354-2355

PALIVIZUMAB

• This is a passive immunization (monoclonal antibody) against RSV

• Provides 40-50% protection against severe RSV bronchiolitis (requiring hospital care)

• Monthly injections given from October to February (RSV season in the UK)

• It is very expensive

Indications

• Premature infants who have CLD

• Children who have problem with the haemodynamic

• Cyanotic congenital heart disease

CHAPTER 2

FLUIDS AND ACID BASE

Normal Fluid Requirements

• The accepted normal volumes of fluid for a normal child is shown in the table below.

• Requirements may be significantly increased or decreased due to problems related to hormonal response, renal function, level of consciousness and disease processes.

For example, a 6kg infant would require 600 ml/day (24 ml/hour)

How much would be required by:

A 14kg child?

A 25 kg child?

A 14kg child would require: 1000 + 200 = 1200 ml/day (48 ml/hour)

A 25kg child would require: 1000 + 500 + 100 = 1600ml/day (65 ml/hour)

• In critical illness or injury physiological mechanisms may be profoundly disrupted and fluid therapy has to be tailored to the needs of the specific child.

• In the presence of acute respiratory or CNS pathology, fluid requirements may be as low as 30 ml/kg/day, while in diarrhoea requirements may be as high as 300-400 ml/kg/day.

• Fluid in the body is distributed into different compartments, including the intravascular, interstitial and intracellular compartments. Fluid does move from one compartment to another, but this depends on factors such as osmotic pressure, hydrostatic pressure and the effect of membranes.

• In small children 70% or more of the body weight may be made up of water, or in other terms: the body consists of 700ml/kg of water.

• Dehydration refers to depletion of total body water.

• Clinical signs of dehydration appear when 2-5% of body weight has been lost. As an example 5% dehydration means that the body has lost 5g of weight for every 100g of body mass (this is of course equivalent to 5ml per 100g, and thus 50ml per kg).

• Clinical signs of dehydration are not reliable measures of hydration. The only objective measure of fluid status is body weight.

• The intravascular compartment is approximately 80ml/kg in volume. Loss of approximately 25% of the intravascular volume (i.e. 20ml/kg), or more, will result in hypovolemic shock.

• It is important to note that fluid moves from the intravascular compartment into the gut in gastro-enteritis.

• If fluid moves out of the intravascular compartment slowly, it may be replaced by fluid from the interstitial compartment (so maintaining the intravascular volume). However, if fluid moves rapidly out of the intravascular compartment rapidly, there may not be replacement from the other compartments and the patient may develop hypovolemic shock with no clinical features of dehydration.

NB

• It is possible to be dehydrated (i.e. have lost total body water) and not shocked (intravascular compartment is not depleted)

• It is possible to be overhydrated and shocked (nephrotic syndrome is an example where the patient is overhydrated as manifest by diffuse oedema and shocked because the low serum proteins mean that intravascular water is not retained)

• It is possible to be shocked and not dehydrated

• The cause of death in children who do not manage their fluid and electrolyte balance is shock, rather than dehydration.

• The treatment of shock requires rapid administration of intravascular volume of fluid that approximates in electrolyte content to plasma.

• The treatment of dehydration requires gradual replacement of fluids, with electrolyte content that relates to the electrolyte losses, or to the total body electrolyte content.

• Damage from electrolyte changes is related to either extreme levels, or rapid rates of change.

• Administration of sodium bicarbonate is rarely indicated.

• Overhydration is potentially much more dangerous that dehydration.

Normal Electrolytes Values

Clinical Signs of Dehydration

ACID BASE

Normal Arterial Blood Gas Values

Abnormalities of Acid-Base

• A drop in pH is referred to as acidosis, while an increase in pH above normal is alkalosis. These may be the result of respiratory or metabolic problems.

• Abnormalities of acid-base that are the result of respiratory dysfunction are generally referred to as respiratory acidosis or alkalosis, while acid-base abnormalities from all other systems are referred to as metabolic acidosis or alkalosis.

Method for Blood Gas Interpretation

There is a simple approach to interpreting blood gases:

Stage 1: What is the pH?

• <7.36 = acidosis

• >7.44 = alkalosis

Stage 2: What is the PCO2?

• Ventilation clears CO2 through minute ventilation

• Minute ventilation = respiratory rate x tidal volume

• If tidal volume or respiratory rate fall, minute ventillation will fall and CO2 rise

• If tidal volume or respiratory rate rise, CO2 will fall

Stage 3: integrating stages 1 and 2

• Increase Acidosis with elevated PCO2 = respiratory acidosis

• Acidosis with low or normal PCO2 = metabolic acidosis

• Alkalosis with low PCO2 = respiratory alkalosis

• Alkalosis with normal or high PCO2 = metabolic alkalosis.

The Base Excess

• The base excess is the amount of base (also known as alkali) that would have to be removed (or balanced with H+) in order to correct the pH to normal, while the base deficit is calculated as the amount of base that would have to be added to the system to correct the pH.

• Acidosis with base deficit (or –ve base excess) = metabolic acidosis.

• Alkalosis with base excess (or +ve base excess) = metabolic alkalosis.

• It is possible for metabolic acidosis or alkalosis to exist concurrently with respiratory acidosis or alkalosis?

1) Acidosis with high PCO2 and negative base excess = mixed respiratory acidosis and metabolic acidosis

2) Alkalosis with low PCO2 and positive base excess = mixed respiratory and metabolic alkalosis

•