PTVAIVTIP EMR Pee PEDIATRIC PPP PE OP Bok Dr. IRFAN MAsoo Scanned with CamScannerCONTENTS [Chapter: 1 History Taking and Physical Examination 1.4 History Taking 4.2 General Physical examination 13. Systemic examination 1.4 Some common presenting problems (Fever, Clubbing, Cyanosis) Chapter: 2 Growth And Development 13 | 24 Growth 22 Primitive reflexes/Newborn reflexes 23 Developmental milestones Chapter: 3 Immunization 19 | 3.1, Immunization terminologies 3.2 Vaccine 33 Vaccination schedule 3.4 Principles of immunization 35 Contraindications to vaccines 3.6 BCG vaccine 3.7 Poliomyelitis vaccine 3.8 Tetanus immunizations 3.9 Hepatitis B vaccine Chapter: 4 Nutrition And Nutrition Related Disorder 25 41 ‘Nutrition 4.2 Breast feeding 4.3 Weaning 44 Micro and macro nutrients Vitamins uses and Deficiency Gs > Malnutrition (Marasmus and Kwashiorkor) 35 Chapter: 5 Neonatology 51 ‘Some important definitions 5.2 Examination of the newborn 5.3 Abnormalities of maturity 5.4 Abnormalities of growth (Large/ small for gestational age) 5.5 Birth asphyxia/Perinatal asphyxia 5.6 Meconium aspiration syndrome 5.7 Respiratory distress in the new-born 5.8 Necrotizing enterocolitis 5.9 Infant of diabetic mother 5.10 Hypogylcemia 5.11 Hypocalcemia 5.12 Neonatal seizures 5.13 Neonatal sepsis 5.14 TORCH infections 5.15 Jaundice Neonatorum 5.16 Polycythemia in the new-born Scanned with CamScanner55 (Chapter: 6 Infectious Disease g Diarrhea (Acute, Chronic, Persistent) “ea Moles es Chicken pox & Shingles 63 Mumps 65 — Malaria 6.6 Typhoid (enteric) & paratyphoid fever 67 Tuberculosis 668 Dengue fever 89 Diphtheria 6.40 Pertussis (whooping cough) 64) Tetanus -6.42- Poliomyelitis 6.13 Pyrexia of unknown origin [ Chapter: 7 Respiratory System _ - - 7 AFA espatgyinteson (AR -2 Pneumonia os; 73. Acute epiglotitis & Viral croup Fog ody 7.4 Pharyngitis (Tonsillitis) an 7.5 Bronchiolitis 76 Pleural effusion 7.7 Pneumothorax N78 Asthma 79 Cystic fibrosis, Chapter: 8 Gastrointestinal And Liver 89 81 Cleftlip and palate 82 — Gastro-Esophageal reflux disease 8.3 Hypertrophic pyloric stenosis 84 — Duodenal atresia 8.5 Malabsorption 86 Celiac disease — QY pape 8.7 Hirschsprung disease 8.8 Inflammatory bowel disease (IBD) 89 Viral hepatitis 8.10. Cirthosis of liver 8.11 Hepatic encephalopathy 812 Ascites Chapter: 9 Cardiovascular Disorders” 104 94 Fetal circulation 9.2 Congenital heart disease (B® Cyanotic heart cisease + Tetralogy of fallot + Transposition of great arteries «Tricuspid atresia 94 Acyanotic heart disease * Ventricular septal defect + Patent ductus Arteriosus > 9.8 Acute Rheumatic fever 9.6 _Infective endocarditis (IE) 9.7 Cardiomyopathy Scanned with CamScannerss SS = sS = = s = = = = = = 2 = = = ~S => = = > = vw @ 7. 5 a e = (Chapter: 10 Neurology 10.41 102 103 104 105 106 107 108 10.9 10.10 10.11 ‘Neural tube defects Hydrocephalus Coma Seizures and Epilepsy Febrile seizures Status epilepticus Pyogenic! Bacterial meningitis ‘Tuberculos meningitis Encephalitis Cerebral palsy Mental retardation (Chapter: 11 Neuromuscular Disorders 131 4 112 11.3 14 15 116 WT Floppy infant syndrome Duchene muscular dystrophy Spinal muscle atrophy (SMA) Myasthenia gravis Guillain-Barre syndrome (GBS) Differential diagnosis of acute flaccid paralysis Bell's palsy (Chapter: 12 Hematology 439 12.4 122 123 12.4 125 126 127 128 129 12.10 12.11 12.12 12.13 12.14 ‘Anemia& Classification Iron deficiency anemia Thalassemia Vitamin B12 deficiency anemia Folate deficiency anemia Aplastic anemia Sickle cell anemia Hereditary spherocytosis G6PD Deficiency anemia : Autoimmune hemolytic anemia Immune thrombocytopenic purpura Coagulation defects (Haemophilia and WWD) -~ [Chapter: 13 Childhood Malignancies 13.1 13.2 13.3 13.4 135 13.6 Leukaemia Lymphoma Childhood primary brain tumors Nephroblastoma (Wilm's tumour) Pheochromocytoma Neuroblastoma 153) [Chapter: 14 Endocrinology 144 14.2 14.3 14.4 14.5 14.6 14.7 14.8 Hormones physiology Hypothyroidism Hyperthyroidism Short stature Hypocaleemia Rickets Cushing syndrome Congenital adrenal hyperplasia (CAR) 461\ Scanned with CamScanner{Chapter: 15 Rheumatic And Vasculitic Disorders 173] 18.1 Juvenile rheumatoid arthritis (JRA) 15.2 Systemic lupus erythematous (SLE) 15.3 Henoch-Schonlein purpura (HSP) 15.4 Kawasaki disease 15.5 Septic arthritis [Chapter: 16 Nephrology And Urology 781] 16.1. Oliguria, Anuria and polyuria 16.2 Hematuria 16.3 Proteinuria 16.4 Acid base disturbance 16.5 _ Nephritic syndrome (Acute post-streptococcal glomerulonephritis) 16.6 Nephrotic syndrome 167 UTI 16.8 Acute Kidney failure 16.9 Chronic Kidney Disease instruments 491 201 X-rays Scanned with CamScannerGrowth and Development ‘Scanned with CamScannerReview of Pediatrics Growth and Development Definition © Its a quantitative change which involves change in size as a whole in separate parts + Assessment of growth: (© Growth is measured by various anthropometric measurements. Which are given below Weight HeightiLength Head circumference Mid-upper arm circumference Weight THis the most common parameter used to measure growh However itis less accurate as itis affected by change in body water and recent meals Anewborn typicaly loses up to 10% of bith weight (BW) inthe first week of fe due to elimination of large amount of extravascular fluid. Should regain or surpass BW by 2 weeks. + _ An infant typically doubles BW by 6 months and triples by 1 year. Weight At Different Ages | WEIGHT (KG) WEIGHT (Ibs) (Rule of 7) 35 7 70 14 | 10 2 | 14 28 \ L 19 43 | Length is measured in lying position and used in children <2 years, \ oe HeightiLength Height is measured in upright position and used in children >2 years. The average child length atthe time of birt is approx, 50cm. It increases by 25em in the first year of if. ‘The height increases by Scmiyr. until puberty ‘After growth spurt (sudden burst) occurs and height increases by 9-10 omiyr. for 2-3, y's. HeightiLength At Different AGE HEIGHT (CM) 50. At birth ‘year 75 2 years 85 3 years 95 4 years 4100 oe seal Scanned with CamScannerad circumference iris The rheasurerent of occipte ronal creumference + Its measured wih tape by placing io encircle head just above the eye brows placed above the eats Growth and Development tothe occipital prominence at the back of the head Head Circumference At Different Ages ‘Age Head Circumference (Cm) ‘At Birth 35. 3 Months a4 Months 44 ‘@ Months, 46 1 Year 47 2 Year 49 3 Year 50. ‘Year St Circumference ‘Wid-Upper Arm | eee TWid-Upper Arm Circumference (NIUAC) isthe circumference of he upper arm, ‘measured atthe mid-point between the tip ofthe shoulder and the tip of the elbow (olecranon process and the acromion) Mid arm/ upper arm circumference is an indicator of nutritional status (mainly protein). Normal value: 12.5em Done up to 5 years of age ba So f Scanned with CamScannerReview of Pediatrics imitive R 1 Primitive Reflexes/ newborn Reflex and Developmental Milestones = Reflox Description ‘Appears | Disappears | CNS Origin Woo Extend head > extension, flexion of | Birth “46mo. | Brain stem arms, legs Vestibular nuclei Grasp Finger in palm > hand, elbow, Bath +8mo, | Brainstem shoulder flexion Vestibular nuclei Rooting | Cheek stimulus > tums mouth tothat | Binh ¥6mo, | Brainstem side Trigeminal system Trunk Withdrawal from stroking along vental | Bith 6-3mo, | Spinal cord Iincurvation | surface Placing | Steps up when dorsum of foot Binh FG mo, | Cerebral cortex stimulated ‘Asymmetric | Fencing posture when supine Birth tot month | 4-6mo, | Brain stem tonic neck Vestibular nuclei (ATNR) Parachute | Simulale fall > extends arms Emo. Never Brain stem Vestibular yaa) yn elny ues + Five main skill areas Visual-motor © Language © Motor © Social © Adaptive +} Assessment based on acquisition of milestones occurring sequentially and at a specific rate ++ Each skill area has a spectrum of normal and abnormal + Abnormal development in one area increases likelihood of abnormality in another—so need to doa careful assessment of all skils ‘Gross Motor Visual Motor Language Social Adaptive | Birth | Symmetric movements in supine object Head flat in prone Visually ices on an ‘leis to sound Regards face | Zmonths | Head in midline while held Follows past midline ‘Smiles in response to | Recognizes parent 7 ees sree sitting touch and voice Raises head in prone Begins to lft chest “Fmonths | Holds head steadily Reaches with both | Laughs Likes to look ‘Supports on forearms in | arms together Orients to voice around prone Hands to midline Rolls from prone to supine ‘months | Sits with suppor (tripod) | Unilateral reach Babbles Recognizes that Feet in mouth in supine | Raking grasp someone isa Transfers object months | Rolls from supine to prone Scanned with CamScanner strangerA ‘Answers all “wh” questions Tells a story Plays pretend Knows alphabet 7 May crawl Starts to sit without support : ‘Smonths | Crawls well Holds bottle “Mama,” “dada, Plays Pee Pulls to stand Throws object (not | indiscriminately gomes i i thi Understands "no" x ‘Starting to cruise overhand) ingests environment gestures (crawling and cruising) 2 May walk alone Crayon marks [2 words other than | Imitates actions months — | (must by 18 months) Object permanence | ‘mama" and “dada” | Comes when (from 10 months) (used appropriately) | called . Follows 1-step Cooperates with command with dressing gesture 15 Creeps up stairs ‘Scribbles and builds | 4-6 words ‘Uses cup and months ‘Walks backward towers of 2 block: Follows 1-step spoon imitation command without (variable until 18 gesture months) 18 Runs ‘Scribbles 15-25 words Imitates parents in months | Throws objects overhand —_| spontaneously Knows 5 body parts | tasks while standing Builds tower of 3 Plays in company blocks, of other children 24 Walks up, and down Imitates stroke (up or | 50 words Parallel play months stairs one foot ata down) with pencil 2-word sentences time Builds tower of Follows 2-step 7 blocks commands Removes clothing | Uses pronouns inappropriately years ‘Alternates feet going Copies a circle 2250 words up the stairs Undresses 3-word sentences Pedals tricycle completely, Plurals Group play Dresses partially All pronouns ‘Shares Unbuttons Dries hands Byears | Skips alternating feet Copies triangie Prints first name Plays cooperative Jumps over lower Ties shoes Asks whata word | games obstacles Spreads with knife | means Abides by rules Likes to help in household tasks Scanned with CamScannerbEbebbeeeOLESEELUUTIVTEMIITII!, immunization Scanned with CamScannerEr OOS Uh TChUhO!OCUhUMhMhUhSFhU?S 4+ Immunization is the administration of all or part of a pathogen or preformed antibodies to elicit an immunological response that protects from disease. ++ Terminologies ‘Active immunity ‘© Is he protective response produced by the Immune system following exposure fo an infectious organism (as infection) or after vaccination (live, killed vaccines or toxoid) Passive immunity © Refers to protection from disease provided by introduction of preformed animal or human antibodies into the body. Examples ‘9 Passage of IgG from the mother across the placenta to the fetus, (© Transmission of secretory IgA in breast mik ‘0 _ Administration of immunoglobulin or antisera to prevent disease, Herd effect or herd immunity © Ia large proportion of susceptible individuals are protected from infection with an organism by simultaneous vaccination, the transmission chain of the infectious ‘agent can be broken by reducing carriage of the causative microorganism by vaccinated individuals, thus decreasing the risk of disease even among the unimmunized individuals, This phenomenon, termed the herd effect Vaccine + Typest ‘A vaceine is composed of one or more antigens of a pathogenic agent which, when administered to a previously unexposed individual, will elicit an immune response but not cause disease. Live vaccines, Killed vaccines, Toxoids , Conjugated vaccines/subunits Live, attenuated vaccines These vaccines contain @ modified virulent organism thathas been weakened so that it produces antigenic response without causing disease. ‘+ Examples: ‘© Mnemonic: My BICEPT. © MMR, BCG, Influenza (intranasal), Chicken pox, epidemic typhus, Polio vaccine (oral), Typhoid (Oral Vaccine). Killed or Inactivated vaccines ‘These types of vaccines are made by kiling tne disease-causing organism with chemicals, heat, or radiation ‘Most inactivated vaccines, however, stimulate a weaker immune system response than do live vaccines. So it would likely take several additional doses, of booster shots, to maintain a person's immunity + Examples: ‘0 Mnemonic: RIP — ACE © Rabies, Influenza (Injectable), Polio (Injectable-SALK), Hepatitis A Cholera, Encephalitis (Japanese encephalitis) Toxold vaccines These are vaccines derived from toxic substances which have been made non-toxic by treating them with formalin (solution of formaldehyde and sterilized water). But their antigenicity is maintained Examples: ‘© _Diphtheria, tetanus Conjugated vaccine A conjugate vaccine is created by covalently attaching a poor antigen to @ strong antigen thereby eliciting a stronger immunological response to the poor antigen. 4 Most commonly, the poor antigen is a polysaccharide that is attached to strong protein antigen + Examples ‘o_ Haemophilus influenzae type b (Hib) Scanned with CamScanner < ohYv ‘Subunit vaccine “Subunit vaccines are vaccines that use only part of the disease-causing virus. > Examples: i Hepatitis B vaccine J Vaccination schedule/Expanded Program of Immunization (EP!) The Expanded Programme on Immunization (EPI) was launched in Pakistan in 1978. Time Vaccine. Dose Site At Birth BCG ‘<1 month: 0.05mi. | Rt. deltoid under the >1 month: 0.4mL_| skin OPVs 2 drops orally | Hepatitis-B 0.6mL 1 At 6 Weeks OPVs 2 drops orally | Rotavirus 2 drops: orally Pneumococcal; 0.5mL_ WM left thigh Pentavalent; (OPT, Hep. 8, Hib) | 0.5mL VM Right thigh ‘ALTO Weeks OPV 2 drops oral Rotavirusz 2 drops orally Pneumococcalz 0.5mL_ WM left thigh Pentavalentz (DPT, Hep. B, Hib) 0.5mL WM Right thigh AL T4 Weeks OPV 2arops orally Pneumococcals 0.5mL WM left thigh Pentavalents (DPT, Hep. B, Hib) 0.5mL. WM Right thigh ‘ALS Months Measels-1 En Tiireht dettaid At15 Months Measels-2 (Optional MMR) 0.5mL 1M left deltoid Principles of Immunization ~ Aminimum interval of 4 weeks is recommended between the admi Exceptions are OPV and MMR and OPV and oral typhoid Killed antigens may be administered simultaneously or at any interval between the doses. o However, a minimum interval of 4 weeks between doses of DPT enhances immune responses. co Agap of 3-4 weeks is recommended between two doses of cholera or yellow fever vaccine. > Alive and an inactivated viral vaccine can be. sciminlstared ‘simultaneously at two different sites, trations of two live vaccines, © Minor illnesses (e.g. Upper respiratory tract infection and diarrhea, mild fever) ‘© Prematurity, History of allergies, Malnutrition, Recent exposure to infection, Current therapy with antibiotics. Live vaccines are contraindicated in children with . ‘© Inherited or acquired immunodeficiency or during therapy with immunosuppressive drugs, Immunoglobulins interfere with the immune response to certain live vaccines like measles or MMR. © Ifimmunoglobulins are administered within 14 days of the vaccine, vaccination should be repeated after 3-6 months. © Immunoglobulins do not interfere with the immune response to OPV, yellow fever or oral typhoid vaccines, Hepatitis B, tetanus and rabies vaccine or toxoid may be administered concurrently with their corresponding immunoglobutin. 4 Antibodies against measles persists up to 6-9 months of age if mother has been vaccinated or suffered from measles, so measles vaccination is given after that age * Scanned with CamScanner GQaaeaoeaonvdnnhihnahtenaininahhenhreahbhenaetkh_aenenrmpeneainrnoeniteinaeuaoeneoroenarContraindications to Vaccines A + Live vaccines are contraindicated in children with ‘0 Inherited or acquired immunodeficiency © During therapy with immunosuppressive drugs, + Individual vaccines Extensive dermatitis Diarthea & within 3 weeks of tonsilectomy -Febriilness, convulsions, Encephalopathy, Not given after 2 years because of neurological complications such as encephalitis, infantile spasms and convulsions -Conwuisions -Anaphylaxis & brachial neuritis BCG Vaccine (Bacillus Ca Guerin ‘+ The Bacillus Calmette Guerin (BCG) vaccine is a live attenuated vaccine that protects against tuberculosis ‘+ BCG vaccine primarily induces cell mediated immunity. + Compl ns! Adverse effects ‘© Ipsilateral axillary or cervical lymphadenopathy ‘0 Koch's phenomenon ie. accelerated reaction which completes in about 40 days co Abscess and ulceration 0 Keloid formation (abnormal proliferation of scar tissue) Vaccines ‘Three types of strains causes polio—type |, Il & II Two types of vaccines are Oral poliovirus vaccine (OPV) Inactivated poliovirus vaccine (IPV) % Developed by Sabin % Developed by Salk Live attenuated vaccine + Inactivatedikiled vaccine + OPV, particularly the serotype 2, %_IPVis incapable by virtue of being inactivated associated with a risk of the vaccine associated paralytic poliomyelitis Include induct ion of both host immunity and [= Notinducing secondary immunity secondary immunity because itis excreted in the stoo! ofthe recipient, and thus immunize, close contacts (Le., herd immunity). 4 Evenifa child has suffered from polo, sil he should be vaccinated so as to protect him from other strains of poliomyelitis Scanned with CamScannerVS ; os Extensive routine immunization of pregnant women wit incidence of neonatal tetanus. Tetanus toxoid schedule for pregnant mothers + f8idose--7" month of pregnancy + 2* doses” month of pregnancy (atleast immunity to the baby due tothe transplacen 4 Tetanus toxin is inactivated by formalin to make tetanus toxoi enhance its immunogenicity + Active immunization Can be given combined vaccine as OPT (diphtheria pertussis and tetanus) + 3 doses at 6 week, 10" week and 14% week as program of EPI ‘© Monovalent vaccine: + 2doses-—0.5mL injected into arm given at 1-2 months interval immunization: 7 This can be done by fh two doses of TT has led to a deciine in the 2 weeks prior to delivery, provides passive tal passage of IgG antibodies) id (TT) and adsorbed onto aluminum salts 10 Tetanus inimunoglobins (TIG) ‘Anti-tetanus serum (ATS) Best prophylactic to use Tris prepared from horse serum Provides protection for 30 days Provides protection for 7-10 days. ‘Dose is 2501U IM Dose is 1500-3000 1U I/M. Tt does not causes serum reactions Test dose is required as it contains horse serum Her is B ine + Dose: ‘© Age less than 19 years~—~0.5mL. cAge more than 19 years-—-tmL “Schedule: ‘© Omonth, 1 and 6 months 4 Infants born to HBsAq positive mothers SS > 0.5 ml of hepaiis Bimmunoglobins (HBIG) within 12hours | SS, after birth and hepatitis 8 vaccine at different site Pl 9 Second dose at 1-2 months , and third dose at 6 month Ro ¢ Atta months ofage, immunized infants level ofhepatisb surface antibodies (Anti-HBs) checked iy + If Anti-HBs positive- vaccination effective SS + IAnfi-HBs negative then check HBsAg * If both HBsAg and Ant-HBs negative-—-repeat the schedule at 0, 1 and 6 months & Infants born to mother of unknown HBsAg status ‘0 Same schedule as above except hat HBIG is withhold until HBsAg status is known If she turned out to HBsAg positive, HBIG should be initiated but within 7 days afer bith. - vaccination ineffective— fi Scanned with CamScanner reaarnearsnapreaerrPrPRPePRRrRRRrRERHRPTyNutrition & Nutrition Related Disorders Scanned with CamScannerETUC E Pediatrics Nutrition & Nutrition Related Disorders ‘Good nutilion Is essential for optimal physical growih and intellectual development. Anealthy diet protects against disease, provides reserve in times of stress, and contains, adequate amounts of protein, carbohydrates, fats, vitamins, and minerals. In order to assess a child's nutritional status and growth, paediatricians follow the patient's growth chart Essential = Nutrients e ‘Cannot be synthesized by the body and must be derived from the diet ‘These include certain vitamins, minerals, amino acids, fatty acids, and a carbohydrate Non-Essential | = Nutrients Can be synthesized pounds or may be derived fromthe d Macronutrionts | ‘Macronutrients supply energy and essential nutrient s needed for growth, development, disease prevent ion, and activity Itincludes Carbohydrates, Proteins, Fats and minerals * Micronutrients | + ‘Micronutrients include vitamins and essential trace minerals (such as iron, lodino, fluorine, zinc, chromium, selenium, and copper, play important roles in metabolism and as enzyme cofactors. Breast Feeding Introduction ‘@ The American Academy of Pediatrics recommends exclusive breastfeeding during the first 6 months of lfe and continuation of breastfeeding during the second 6 ‘months for optimal infant nutrition. Pathophysiology | * Stimulation of areola causes secretion of oxytocin Of Milk + Oxytocin is responsible for let-down reflex when milk is ejected from cells into milk Production ducts 4+ Sucking causes release of prolactin, which triggers milk production Benefits e ‘© Lower incidence of infections, including otitis media, pneumonia, sepsis, and meningitis ‘© Breasted infants are less likely to experience feeding difficulties associated with allergy (eczema) or intolerance (calc). ‘© Human milk contains bacterial and viral antibodies (secretory IgA) and macrophages. ‘© _Lactoferrinis a protein found in breast milk that increases the availabilty of iron, © Easily digestible, nutrients well absorbed, Less constipation 0 Increased attachment between mother and baby Mother Bonofits ‘0 Easier postpartum weight loss (© Decreased postpartum bleeding due to oxytocin release © Increased bonding ©. Delayed postpartum fertility ©. Faster return to preconceptional uterine siz © Decreased risk of breast and ovarian cancer ‘Special ‘% Breastfed infants should receive oral vitamin D supplementation, beginning within a Consideration week after birth to prevent rickets 4 _Itis recommended that all children receive a minimum of 400 1U of vitamin D dail Contraindications | HIV SERBKEEESESEECHEEHEESEEEEEEEOEEEELEE Scanned with CamScanner‘Chapter 4 Nutrition & Nutrition Related Disorders CCHIV, HSV (ifiesions on breast) HBV (Mothers with HBV infection are free to breast feed their infants after the neonate has received the appropriate recommended vaccinations against HBV) ‘Acute maternal disease if infant does not have disease (tuberculosis, sepsis) Breast cancer Substance abuse Drugs: © Absolute contraindications: + Antineoplastic, radiopharmaceuticals, ergot Alkaloids, iodide/mercurial, atropine, lithium, chloramphenicol, cyclosporine, Nicotine, alcohol © Relative contraindications: Neuroleptics, sedatives, tranquilizers, Metronidazole, tetracycline, sulfonamides, steroids 4 Breast feeding is not contraindicated in mastitis, Correct Position | = The baby's head and body should be ina straight ine Of Breast His face should face the breast, with his nose opposite to the nipple Feeding + His mother should hold his body close to her's, with lower lp well below the nipple 4 _Ifbaby is new-born, support bottom as well Problems Of % Insufficient milk syndrome Lactation And © Cause Their * Anxiety most common cause Management + Others include delayed initiation of breast feeding, infrequent feeding and supplemental feeding © Management: ‘+ Reassurance, advise to increase fluid and dietary intake, counsel on ‘optimum breast feeding practice Breast engorgement © Causes: + Delayed initiation, infrequent breast feeding | © Management +” Apply warm compresses, massage, breast fed enough to empty breasts * Mastitis 0 Causes + Obstruction of lactferous ducts + Cracked nipple + Breast engorgement © Management: + Watm compresses, analgesics and antibiotics 4 Breastfeeding jaundice--explained in neonatology chapter ‘Comparison of Breast Milk to ‘Component Human Milk Cow Milk Cow Milk Waterisolids ‘Same ‘Same Calories 20 calloz 20 calloz Protein 1=1.5% (whey dominant) | “3.3% (casein dominant) Carbohydrate 6.5—7% lactose 4.5% lactose Fat High in low chain fatty | ~ High in medium chain acids, fatty acids Minerals Tron better absorbed Low iron and copper Vitamins Diet dependent, low in K Low in C,D Digestibility Faster emptying ‘Same after 45 days Scanned with CamScannerWeaning ~ Definition $_Itis defined as introduction of food other than mik (semi-Solds Toodsy Pins of weaning | 3 Wis stated at 46 months of age (ypicaly at 6 months of age) Food lron-foried cereal only at 46 months * Step-wvise introduction of strained foods (vegetables and fruits), then dairy, meats (6-9 ‘months; stage | and I) & Atone year of age child requires 3 mealsiday and 2 snacks in between % Note: No honey in frst year of life Macronutrients Proteins Proteins are converted fo pepiides and amino adds % Ofthe 20 amino acids, nine are essential, i * As compared with adults, infants require more protein in their diet (2.2 g/kg during Infaney decreasing to 0.8 glkg during adulthood). : * Essential amino acids (Mnemonic: BVT TIM HaLL) ~Bhenylalanine, Valine, Threonine, tophan, jsoleucine, Methionine, Hisiidine, Leucine, Lysine Carbohydrates make up approximately 50% of a typical diet Ate converted by the body to glucose and other monosaccharides. % Carbohydrates are stored as glycogen in liver and muscles, Fats Fats are broken down into falty acids and glyceral % Essential fatty acids play an important role in infant brain development. ++ Less than 30% of al calories should come from fats. Minerals, including sodium, chloride, potassium, calcium, phosphorus, and magnesium, are also required dail Micronutrients “Includes Vitamins + Classification of Vitamin Fat soluble vitamins Water soluble vitamins = Vitamin A, D, KE ‘® Vitamin C (ascorbic acid) ‘Toxicity more common than Vitamin B complex. for water-soluble SS ee ee Scanned with CamScanneritamin [eee Deficiency Vitamin A” Essential for normal diferentation of % Dry skin epithelial celis % Night blindness + Strengthening immune system % Comeal degeneration * Used to treat measles and Acute % Bitot spots promyelocytic leukemia % Inexcess: teratogenic Vitamin B1 | Cofactor for enzyme reactions % Dry beriberi: polyneurilis, symmetrical (thiamine) muscle wasting % Wet beriberi: high cardiac output failure a (dilated cardiomyopathy) | j Vitamin B2 ~~) Component of flavin FAD and FUN # 2C's: Chellosis and Comeal | (Riboflavin) | + _B2= gives two ATP by FAD and FMN vascularization S ! Vitamin B3 ‘* Component of NAD and NADP. Hartnup disease: (Niacin) Derived from tryptophan % Pellagra: 3D's: Synthesis requires VIT Bz AND Bs © Diarrhea, Dementia, and B3=3ATP Dermatitis (collar rash-like Used to treat dyslipidaemias necklace) Component of co-enzyme A # Dermalitis, alopecia | Vitamin 86 4 Required for synthesis of heme, * Peripheral neuropathy (Pyridoxine) histamine, and neurotransmitter like GABA | Convulsions | and dopamine % Sideroblastic anemia | Vitamin B7 | & Cofactor for carboxylation reactions | (Biotin) Actas cofactor in oxidation of fatty acids Vitamin BS ‘Converted to THF acid, important for Deficiency causes macrocytic | (Folate) synthesis of nitrogenous bases in DNA megaloblastic anemia. i and RNA Most common vitamin deficiency in US. | Found in leafy vegetables * Deficiency in early pregnancy causes 4 Absorbed in jejunum neural tube defects in new-born. Vitamin B12. [% Found in animal products Macrocytic megaloblastic anemia (cobalamin) | + Deficiency caused by malabsorption (e.g., | Paresthesias sprue, enteritis, Diphyllobothrium latum), | Neurological problems lack of intrinsic factor (pemicious anemia), 1 Vitamii Anti-oxidant ‘ SGurvy due to Collagen synthesis defe= (Ascorbic * Facilitates iron absorption i acid) 4 _Necessary for collagen synthesis | Vitamin D Vitamin D form: © Rickets (children) 0 25-OH D3 = storage form. % Osteomalacia (adults) © 1,25-(OH)2 D3 (calcitriol) = active | Breast fed infants should receive oral fom. vitamin D. | Vitamin E Antioxidant Muscle weakness. (tocopherol) | Can enhance the anti-coagulant effect of | Neurologic presentations like B12 warfarin deficiency + Hemolytic anemia Vitamin K % Blood clotting ‘Neonatal Hemorrhage (Neonatal (Kis for + Synthesized by intestinal flora hemorthage with “PT and ‘SaPTT but Koagulation) | + Necessary for maturation of factors 2,7,9, | normal bleeding time) 10 and protein c and Zinc Essential for activity of 100+enzymes Delayed wound healing “+ Hypogondisam 4 _¥ adult hair (axillary, facial, pubic) Scanned with CamScannerrE SS©SSLCRHOHHLHEHHHOHSHHKEHYKEKEKEBKEKLBEEBEKEE ‘Review of Pediatrics / Yv Malnutrition/ Protein Energy Malnutrition (PEM) ‘Definition: ‘© The World Health Organization (WHO) defines malnutrition as “the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, ‘maintenance, and specific functions" ©. The term Protein-Ener “Malnutrition (PEM) applies to a group of related disorders that include ee marasmus. % Etioloay™ © Primary Malnutrition + Due to lack of foods © ‘Secondary mainuttion +” Malnutrition occurring as a consequence of underlying chronic disease Classification In this, weight is assessed at various ages by standard weight charts + Ifweight is less than expected for that age, then child is considered malnourished Nutritional status Weight for age (% of expected) Normal 290% 4" degree PEM 75-90 2 degroo PEM 60-75 3 degree PEM Tess than 60 jateriow “This classification takes into account height of child in addition to his weight. Classification Nutritional status ‘Stunting (%) ‘Wasting (%) Height for age Weight for height Normal >95 330 Mild (Grade 7) 75-95 80-0 Moderate (Grade 2) 80-875 70-80 Severe (Grade 3) <0 <70 This classification takes into account the cinical features of edema in addition to weights Edema present Edema absent Weight for age 80-60% of Kwashiorkor Ponderal retardation standard Weight for age <60% of | _ Marasmic kwashiorkor Marasmus standard + Investigation ‘0 Blood glucose-—-—-glucose <54mg/DI indicates hypoglycaemia Blood Montat ecc000 > PEM/ Malnutri ° Marasi Serum electrolytes ‘CBC showing Hb, TLC, peripheral smear culture, Urine culture ux test Serum proteins ition Manifests as: mus © Kwashiorkor ° Marasi smic kwashiorkor. Scanned with CamScanner Chest X-ray--to rule out pneumonia, bones showing rickets etc., heart failure: Kwashiorkor [ Marasmus 7 RSeveSps in chieren whose its ave dali af | @ tia dw To daiioney of proteins and calories ] Proteins 4 Diets deficient in calories but na nutrients are = centroly absent, | e | Shr AS gommon in chisien between 6 months and 3” | # tis eomman in ifants under 1 year of age but |__years of age. but can of ‘atte ater san coun lit chien o2 Gane ___ aaareen pace > Low proton hake Wo" Har of decreased or abort = Evtreme searety ef food breasteetng | Low level of education (People who do not Fesingalvesmictoma | gE understand how teat ae ay so Delay neuer Td ood ¥ Cinealtoatures ae Cinical Features | Woon face © Old man appearance — Mild retardation o Severe retardation | <7 Abdomen is protuberant o Abdomen in shrunken > Faty ver change due to Lapolpopetin 8 _ Moses WaT synthesis) _—= | 2 jons | » CEédemardue tou plasma oncotic pressure & | Tver malfunction, © Clinical picture is small child with swollen © Clinical picture is that of a child who | abdomen Stoller | looks like an old man %” Mnemonic: Kwashiorkor | esults from protein deficient | & Mremonie Marasmus results a Muedle ] MEALS: wasting | 9 Malnutrition | fF -6"Bdame | 2 Anemia | Liver (fatty) | 2 Skin lesions (hyperkeratosis! \ a hyperpigmentation) ba Se: Kwashiorkor ‘Marasmus Protuberant ly Prominent bones Decrease in sub-cutaneous fat Mtchy rash ‘Xerosls Loose skin’ Poor wound healing Scanned with CamScanner~" FFF FTHYUHHHOHKLKEKKHKBKEKEKEKEEELESL SA Management OF Mild To Moderate PEM Management OF “Counseling & education of parents on Featvaag nition © Having a healthier, more balanced diet © Ealing “Yottiea foods that contain extra nutents © Snacking between meals © sg hiaving drinks that contain lots of calorie Cate during common ilness including iarhen ‘Micronutrient supplementation Growth monitoring and pramotion strategy Pas Severe Malnutrition Acute Phase Management + Managing ite threating conditions © Hypoalycaemia + Itcan be prevented by frequent feeding “ron hiPOalvcaemia Suspected give 60 ml. 10% glucose or sucrose © Infection * Antisiotcs for proven infection * Children with complications (such as hypoglycaemia, hypothermia, ‘kin infections or who eppear lethargic or sick) shouldbe given antibiotics © Hypothermia * _ Rewarming i temperature below 35 C with extra clothing or placing near a warmer © Dehydration * Dehydration corretion should be done with 12 hours * Mild to moderate dehydration can be corrected with ORS * Severe dehydration and shock can be corrected with IV therapy © Electrolyte imbalance ‘+ Don't give high sodium to oedematous child * Give extra potassium 3.4 mmolkgiday + Give extra magnesium 0.4-0.6 mmolkglday © Micronutrient deficiency + Oralironis not given until infection is not resolved ‘Vitamin, Folic acid and zine supplementation + Nutritional Rehabilitation Phase: (© This phase is to recover the lost weight by excessive feeding © Dietary management is maintained at 150-250 kcalkglday and 3-59 proteins/kg/day Micronutrient deficiency correction is continued ‘The mother's trained to continue care at home This phase takes 2-4 weeks Follow-Up Phase at The aim is to prevent rl Ensure proper development of growth and mental development RS eee 4 Scanned with CamScannerNeonatology Scanned with CamScannerLN SE ett TEL tees Some Important Definitions Neonatal Period Iti defined as firs 28 days of ife of ave born 4 Itmay be further divided into og ata period: From birth to 7 dBy (.. rst week of lve) Lat 1 period: From day 8 to 28 days Bf feof alive born infant. nt of any Gestation? (i.e. from bith til 4 weeks) infant, 7 + itis defined as 8 year #f age" or more simply “Achild under the age, qe = sy inatal, P1 nd iod: Bainter Borlod [= WHO defintion: the period that exiende rom 22 weaks of gestation 10 7 days ale? bith Bra Natal Pariod [2 The period that occurs before bin during or elatng to pregnanc Post-Natal The period after bith Period I e, Preterm and Po: onal =e Arneonate born before 37 weeks of gestation ifespedive of the bith Welght =e Rnsonate born between 37 10 42 weeks of gestation 7 Kneonate born after 42 weeks of gestation Pre-torm Neonat Full-Torm Neonate Post-Term Neonato ' till Birth, iv ok definiions can vary from state to stat in terms ofthe gestational age Remember nese ee WHO definition: Pregnancy termination prior to 20 weeks’ gestation (age of viability) (Aborion ora fetus born weighing less than 500 g Pita death at a gestational age of 22 weeks or more or weighing more than 600 @ at ‘Sa Birth Lee zt oT conception, Wespetlive oT Weg or Geslatanal AGE, Tat wer Live Birth ‘A Pisration from the mother, shows any evidence of lfe (e.g. breathing, hear-beat pempereee ity: ee Me es ‘Definition Causes. = [Mortality Tyee | ___-s scrtion: Refers 0 Yelal deaths |S ABruplo placenta Perinatal aerurring from 22" week of gestation | < Intrauterine asphyxia Mortality ratio ecto Tday of ife per 1000 total bith | > Intrauterine infectons “oralso defined as = Mutiple gestation ‘Number of still Births: and early ‘+ Umbilical cord accident fal deaths per 1000 total birth | Maternal underlying disease (0.9. neona x = janis hypertension, Diabetes TATE Gays TE aT espratory dattess Syndrome [raceme in frst 28 " ‘Neonatal Nooo lve births per yea 3 prnewne™ Reena jth trauma % Congenital anomalies Infection Pt intestine Scanned with CamScannerwborns Classification According To Weit sai Low birth weight neonate | Neonate having birth weight less than 25009 (2.5ka) irrespective of gest Gime WUE nal neonate fional ‘Vary Low birth weight | Neonato having Bith weigh ess than T5009 (Taxa) wrespectve of gestational age age Extremely low birth weight | Neonate having bith weightless tan 1000g (1 Ka) ivespecive of gestational | age Examination of the Newborn 4 _ Examination of the newborn that difers from those of children and adolescents include: 4 General ‘Appearance e * ‘Assess spontaneous activity, passive muscle tone, respirations | Look for any abnormal signs such as cyanosis, intercostal muscle retractions, or meconium: staining ‘APGAR Score Measured at 1 and 5 minute ater bith, and continue every 5 minutes unti final score of 7 | ‘or more is reached Low APGAR score indicated the need (or resuscitation and indicates poor ‘Skin Examination i | Craniofaciar Examination Texture differs win gestational age {Lanugo— thin hair that covers the skin of preterm infants I infants Colour--1ook for colour ofthe skin © Normally pnk—few hours after bith © Blue colour (cyanosis)~indicates respiratory distress © Pallor-—- indicates anemia, sepsis, neonatal asphyxia, shock Jaundice: © Woccur within 24 hours~is always abnormal _Woccur after 24 hours and seen in fist few days of lif is normal Head © Microcephaly- newode opment olson 7 \ minimally present in term head circumference below the 10th percentile ‘© Caput succedaneum-—difuse edema or swelling of the soft tissue of the scalp ‘© Cephalohematomas~sub-periosteal hemorrhages secondary to birth trauma © Craniosynostosis —~-pre-mature fusion of the cranial sutures, results in abnormal \ skull 0 Craniotabes: soft areas of the skull wth a “Ping-Pong ball’ feel, fe Eyes ‘An abnormal red reflex of the retina may be caused by cataracts, glaucoma , fetinoblastoma, or severe chorioretinitis, Wose =e =| Examined immediately to rule out unilateral or bilateral choanal atresia. 4 It this is suspected, itcan be excluded by passing a nasogastric tube through each nostri, Mouth Examine for © Cleft lip and palate © Micrognathia—a small chin, should be noted if any ‘©. Macroglossia -~ large tongue ‘o_ Neonatal teeth -- may be seen rarely, usualy in the area of the lower incisors ‘Neck And Clavicle Examination $ Clavicle —-should be examined to rule out fractures Edema and webbing of the neck suggest Turner syndrome Lateral neck cysts or sinuses---~include branchial cleft cysts and cystic hygromas. Chest Examination seleoe Midline clefts or masses —indicates thyroglossal duct or by goiter \ ‘Accessory nipple which may be present along the anterior axilay or mid-clavieular Congenital deformities such 2s ines ‘© Pectus carinatum (prominent and bulging sternum) ‘0 Pectus excavatum (depressed sternum). ‘0. Chest asymmetry—as a result of absence of the formation of ribs or ag, the pectorals muscle : Respiratory distress ~~ diagnosed if tachypnea (RR > 60/min), cyanosis eS S Ears examined for Appropriate shape & location, Pre-auricular tags or sinuses & © S ¢ « « , }enesis of Scanned with CamScannera + Theludes examination of Heart rate, mhyhm, assessments for murmurs and peripheral eaination pulses. ‘0 Diminished femoral pulses——~Consider coarctation of the aorta. o__Increasedfernoral puses-—---Consider patent ductus arteriosus edominal | Unbiicus Betmination ‘©The umbilical cord should be inspected o confirm the presence of two arteries and one vein ©The presence of only one umbilical artery may suggest congenital renal anomalies. $ Umbilcal emia 0 Caused by the incomplete closure of the umbilical ring. ‘0 Most close spontaneously and usually no treatment is required. ‘© Those that persist beyond 4-5 years of age may require surgical treatment Genital examination ~-check for hypospadias, Epspadias, hydrocele Heurological | ¢ Evaluation of muscle tone, level of alertness, and primitive reflexes should be performed Examination Abnormalities of Maturity Preterm Delivery Post-term Delivery + Apreterm deivery occurs less than 37 © Apostterm delivery occurs 42 weeks ormore ‘completed weeks from the first day ofthe last. from the first day of the last menstrual period. menstal perio. “ ~Complications ‘Complications 0 Perinatal asphyxia © Placental insufficiency ‘o Hypothermia ‘©. Severe intrauterine asphyxia ‘0 Hypoglycemia c_. Meconium aspiration syndrome, © Hypocalcemia © Polyeythemia ‘0 Respicatory distress syndrome Patent ductus arteriosus 0 Intracranial hemorrhage 0 Necrotizing enterocolitis 0 Infections Abnormalities of Growth ‘Small For Gestational Age (SGA) Large For Gestational Age (LGA) Definition [| % Baby whose birth weight is less than 10th ‘~ Baby whose birth weight is above 90th percentle for his gestational age percentile for his gestational age Etiology | Maternal % Constitutionally large babies: most ‘0. Systemic diseases in mother ‘common cause (Hypertension, Diabetes. CKD) ‘Infants of diabetic mothers 0 Matemal Malnutrition. ‘ Erythroblastosis fetalis ‘© Smoking in pregnancy. Beckwith syndrome 0 Multiple pregnancy. — Manage complications listed above Se + Tube feeding (fhe baby does nothave a | occurred ‘trong suck) Ss Checking for hypoglycemia ~~. Monitoring of oxygen levels & management Scanned with CamScannerBirth Asphyxia /Perinatal Asphyxia /Neonatal asphyxi ‘Definition: # me ‘© Asphyxia means Jack of oxygen and blood flow to the bran, © Birth asphyxia nageane whch a baby's brain and other organs do not get enough oxygen and nutrients belo, during or ight ETON atu % Failute of inihation off Breathring « —e pape isk f Maternal YS Increasing or decreasing matemal age Cor CEP Hypertension, including eclampsia and preeclampsia. grwe_7ocrerUle Pelvic abnormality a % Diabetes melitus. f+ Hypotension. 4 Infections, ‘Maternal hypoxia from cardiac and pulmonary disease. Placental} Prolonged rupture of membranes y--Placental insufficiency due to toxemia or post maturity. - Fetal “Cord prolapsed or compression. 4 Abnormal le or presentation, 4 Prematuriy, ty Anemia, * | infections. ‘3 Hypoxia due to pulmonary or cardiac problems. + Diagnosis: ‘© Diagnosis can be made using Apgar score i ‘Apgar score 0 i 2 \ Beara (Bkin-coiour) | Blue, pale Body pink, Fully pink extremities blue | Puise (heart rate) ‘Absent Below 100 ‘Over 100/min Grimace (response to No response Facial grimace Cry \etimulation) paety (muscle tone) Flaccid ‘Some flexion Normal with movernents \ Respiratory effort ‘Absent Gasping Regular 7 Normal score ~ 7 — 10 score. Fairy low- 4-6 score, Critically low - 3 and below % These 5 variables are evaluated at 1.& 5 minutes after birth, and each one is scored from 0 to2. - 4 The final score is the sum of the five individual scores, with 10 representing the optimal score, ~ S 4% _Scofing should be continued every 5 minutes until a final score of 7 or more is reached + \cofaplications: CNS Hypoxic ischemic encephalopathy Kidney ‘Acute tubular necrosis Respiratory Respiratory distress syndrome, Meconium aspiration, apnea Git ‘Necrotizing enterocolitis. + Ménagements 5 ° establish patent airway, suctioning, if necessary endotracheal intubation é a ° ‘olume expanders in case of hypovolemia, Chest compressions if needed 0 D=Drugs ae * Epinephrine (adrenaline): 1:10,000 concentrations, 0,1-0.3ml/kg IV + Sodium bicarbonate: given in metabolic acidosis at dose of 2mEqikg IV slowly e + Phengbarbitone: used in seizures in infants, Diazeoam should be avoided Scanned with CamScanner| E Review of Pediatrics Respiratory Transient Meconium distress tachypnea aspiration syndrome ofthe —_ syndrome newborn Pneumonia Diaphragmatic hemia Choanal atresia Cardiac: cyanotic CHD Heme: anemia, polycythemia ‘Other: infectious, metabolic, neurologic Meconium Aspiration Syndrome (MAS) & Transient Tachypnea of the Newborn Meconium Aspiration Syndrome ‘Transient Tachypnea of the Newborn | Definition |4¥ Meconium (first stools) is a material in| * Transient pulmonary edema resulting from the fetal gut | 8° MAS describes an acute respiratory VU disorder caused by the aspiration of ‘meconium into the airways of the fetus orneonate. _ “ Meconium is offen passed as a consequence of distress (ie., hypoxemia) in the fetus at term and becomes more frequent after 42 weeks ‘Occurs in both term and preterm. infants more common in infants delivered via C- section (especialy if delivery takes place before the onset of labor) | gestation. Presentation Presents within 12 hr. of birth with progressive tachypnea, flaring, grunting; ralesirhonchi on chest examination; “barrel” chest Presents shorlly after birth with tachypnea ‘and occasionally grunting and nasal fiaring | Arterial blood Significant hypoxemia, hypercapnia Respiratory acidosis (UpH, 4PaCO2), Mild-to-moderate hypoxemia (VPa02) gas changes ‘Chest ‘meconium in the delivery room if indicated Areas of patchy atelectasis, Prominent penihilar streaking 4 coarse irregular densities interspersed | ¢ Increased interstitial markings fluid in the with areas of hyperinflation interlobar fissures E Mechanical ventilation with high % O2 therapy ‘concentration 4 Continuous nasal positive ainvay pressure 4_Opand high mean airway pressures itneeded “Removal of oropharyngealitracheal = None known * Incidence lower in babies born vaginally, ‘and those bom via C-section folowing a period of labo Scanned with CamScannerChapters ‘Neonatology, Respiratory Distress Syndrome OR Hyaline Membrane Disease © Defi + * ‘RDSis dened as he yespsatorf distress caused by a lack of surfactant, most frequently in pusiaum infants = “> Pathophysiology: + lt resuls from a delicacy ot aufactant “5= Surfactantis produced by type Iloneumocyte cells in the pulmonary epithelium, \ Ae surfactant ining the alveoi reduces surface tension, improving lung compliance and preventing full alveolar colapse during expiration. ersely. surfactant deficiency results in poor compliance, leading to progressive atelectasis, hypoxemia, and cyanosis Since fetal lung matunty 18 ge erally attained by 34 weeks’ gestation, RDS is considered a disease of (ematurty, and the ndeace increases vith decreasina gestational age © However, RDS does occur uncommon in term and near-term infants ether through incorrect dating of the pregnancy or delayed cell maturation’surfactant production. + For example“te Combateref ftathyperalycemia and hyperinsulinemia in maternal diabetes may resulln delayed producto at sutacian, Risk factors: Conigiations: Premauniy. ieieraseon Multiple pregnancy | 0 Intraventricular hemorrhage © Mother with previous preterm infant with RDS ° Bronchopulmanary dyspleda foher vith Gabetes melius © pneumothorax Necnatalhypotemma/ © Neonatlasehpi/ wracorre! Alecnabd Clinical features: Hegel] 4 ee elnfe genta! pyaar Chest wall retractions Geo Lxpiratory grunting and nasal faring ntoloce) e { |. Preratut oun badd E PPS : y pratare) OP» Bypeber/y Diagnosis: : © Prior to Birth (Fetal ite) : 2 ‘Presence of surfactant in amniotic uid obtained by amniocentesis. * Alecithin-to-sphingomyelin (L:S) ratio less than 2:1 © Alter bith CXR: + Diagnostic ‘+ Findings: diffuse atelectasis, ground-glass appearance of the lungs, Air bronchograms + Management: ‘© Supplemental oxygen is necessary. © Continuous positive airway pressure (CPAP) + Atechnique for maintaining ond-expiratory airway pressure greater than atmospheric pressure forthe spontaneously breathing infant, promotes air exchange © Mechanical ventilation may be indicated i hypercarbia and respiratory acidosis develop ‘© Exogenous surfactant administration is often curative. Scanned with CamScannerReview of Pediatrics Proverition: © When preterm delivery cannot be prevented, administrat on of corticosteroids to the mother 48 hours before delivery can induce or accelerate the production of fetal surfactant and minimize the incidence of ROS. In fact, antenatal steroids are administered to all women at risk for preterm delivery prior to 34 weeks" gestation, ‘© Surfactant can also be administered to infants soon after birth via endotracheal tube Necrotizing Enterocolitis (NEC) [ Definition Necrotizing enterocolitis occurs when the intestinal tissue becomes damaged an Epidemiology. | * Most common surgical conditions in neonates Itis most frequent in preterm infants, ‘Abdominal distention Blood in the sto! Metabolic acidosis Lack of energy Vomiting : i ray abdomen 9 abdominal distension © Gietuid levels, thickened bowel walls 2 Br Sumatosis intestinals (arin the bowel wal), on plain abdominal im is pathognomonic Breumoperitoneum is suggestive of perforation agement PO | © nasogastic tube is inserted to relieve distension and to aspirate stomach | contents Give intravenous fluids / TPN V Antibiotics | Treatment of thrombocytopeniavanemia, DIC Clinical features Diagnosis nagement > Suraical Pralorator laparotomy vnh Resection cof necrotic bowel 2 =F adhesic trictures), ‘a obstruction (e.g., adhesions, strict ‘° Ieee aetciences (2... malabsorption, short gut syndrome) Nutr Cholestasis. oe ees Complication’s | pee pneumatosis £2 intestinalis Scanned with CamScannerInfant of Diabetic Mother Definition \Chapter5 Es ‘An infant ofa diabetic mother is a baby who is bon to @ mother with diabetes whose blood sugar (glucose) levels remained high throughout her pregnancy. Clinical features Large and plump baby (macrosomia). Putty Plethoric Face (round moon face), Fetal hyperglycemia and fetal hyperinsulinemia due to maternal hyperglycemia ‘Complications ooo Felus may die suddenly during the last trimester of pregnancy Macrosomia (large size of the body) may result in © Birth trauma © Asphyxia © Increased possibilties of caesarean section Neonatal respiratory distress Metabolic problems such as ‘© Hypoglycemia & © Hypocalcemia Hematological problems © Palycythemia © Hyperbiliubinemia Higher risk of congenital anomalies (most commonly cardiovascular defects) Management: ale ‘The infant should be screened for malformations and injures. Frequent breastfeeding should be encouraged. ‘The neonate should be monitored for blood glucose levels during fist three days of lite The other morbidities such as respiratory distress, hyperbiliubinemia should be treated appropriately. Hypoglycemia Definition Hypoglycemia is serum glucose concentration below 40 mg/dL. Neonatology Etiology Conditions That Result in insulin | Conditions That Result in Diminished Excess, Glucose Production Infants of diabetic mothers (IMs) TGR commonly have transient + preterm infants with limited hepatic hypoglycemia, ‘glycogen stores and poorly + Insulin-producing tumors or islet cell | __ developed gluconeogenesis hyperplasia have Persistent + Asphyxia’ hypoglycemia & Sepsis 4 Inborn errors of metabolism Clinical features ‘Sweating % itteriness (Tremors) Feeding problems Tachycardia Hypothermia > Hypotonia Seizures: 4 Myocardial infarction (rarely) Diagnostic workup Blood glucose level 4 For high risk patient © Infants at risk for hypoglycemia should be screened by measuring blood sugar by Glucometer at ages 1, 2, 4,6, 9 and 12h. Less frequent measurements are appropriate if blood glucose is stable. Scanned with CamScanner~ Ss = ~~ ) 3 3 S 3 > > 2 3 9 2 3 2 3 3 3 S 3 3 = 3 3 3 =) 2 2 Review of Pediatrics RBS 240 mg/dl, ° follow usual nursery protocol | Early feeding of the newborn with breast mitk or formula is encouraged. RBS 20-40 mg/dl. Feed 5 mkg of DSW. | Repeat blood glucose or Glucometer 20 min after feeding. If RBS still low—- Begin continuous infusion of D10W at 4-6 mg/kg/min. | Repeat blood glucose in 20 min and pursue treatment unt blood sugar >40 mgidh. | For persistent hypoalycemia despite above measures: Dextrose 12.5% in peripheral vein | Surgery in case of insulin producing tumors Hypocalcemia Introduction Clinical features | | | | = Definition: Hypocalcemia is defined as total serum calcium level of <7 mg/dL or | ionized calcium level of <4 mg/dl. Hypocalcemia may be of early onset (<72 hr.) or rarely late onset (>72 hr). Early onset neonatal hypocalcemia: Commonly seen in preterms less than 32 weeks | Infants of diabetic mothers, | Perinatal asphyxia Maternal hyperparathyrcidism, Late onset hypocalcemia Usually asymptomatic. Neuromuscular Cardiac ‘Serum calcium level of <7 mg/aL Ionized calcium level of <4 mg/dL. ‘Asymptomatic hypocalcemia ‘Symptomatic hypocalcemia Neonates born to mothers with vitamin D deficiency Babies on anticonvulsant therapy or with malabsorption Babies on cow milk feeding Hypoparathyroidism ‘Myoclonic jerks Jteriness Exaggerated startle Seizures, Tachycardia Hear failure Proionged QT interval or Normal maintenance Ca++ in their IV fluids They should receive a bolus dose of 2 mi/kg/dose. This should be followed by a continuous IV infusion of 80 mg/kg/day elemental calcium for 48 hr. Calcium infusion should be reduced to 50% of the original dose for the next 24 hr. and then discontinued The infusion may be replaced with oral calcium therapy on the last day. Bradycardia and arrhythmia are known side effects of bolus IV calcium ‘Administration and bolus doses of calcium should be diluted 1:1 with 5% dextrose and given under cardiac monitoring. | | { | | | Scanned with CamScannerNeonatal Seizures ‘Neonatology, (TEC) ‘the first 28 days of ife is called neonatal seizures: + Hyporic ischemic encephalopathy (almost 50% cases) Binh asphyxia 4 Developmental malformations 4 Intraventicular, intracerebral hemorthage 4 Maternal withdrawal of medications 4 Transient metabolic ‘© Hypocalcemia, hypomegnesaemia, hypoglycemia Infections: © Meningitis, septicaemia tetanus neonatorum, itrautenne infections + Metaboli errs: o_Phenyiketonuna, maple syrup urine sisease, gatactosemia. | | | = EES \ = CBC | 4 Serum Glucose, calcium & magnesium levels 4 Urea, creatinine and electrolytes 4 Blood culture " | al 4 Lumbar puncture to rule out meningitis t __| s+ Metabolic profile in case of inborn errors of metabolism: saad ee i Management | Hypoglycemia and hypocalcemia should be corrected before the administration of | oon | ow 1 4 Step 4: Give 10% dextrose water 2-4 mifkg IV to control hypoglycemia, if controlled give Continuous infusion, | e 4 Step 2: If not give 10% calcium gluconate 2itilkg IV slow if controlled give maintenance | ‘calcium IV. | o | 4 Stop 3: Ifnot- than anticonvulsant therapy ‘0 Phenobarbitone isthe drug of choice, altéfnatve is phenytoin | ‘0 Diazepam = if not controlled with Phenobarbitone 4 e e Note: 4 4 tis important to distinguish between jteriness and serzures, as both can be confused with one another Neonatal seizures vs. Jiteriness i 4 ‘Characteristics Seizures, ‘itteriness \ 4 Can extemal stimul initiate? TNO ‘Yes | Movements Irregular and Jerky ‘Symmetrical fine tremors ‘ ‘Associated rise in heart rate Yes No | ‘Can movements be easily No Yes, by Gently bending or holding | « stopped limb | d 1 Scanned with CamScannerNeonatal Sepsis Definition 'tis a bacterial infection in neonate (First 4 weeks of life) documented by positive blood culture. T Early Onset Sepsis Neonatal sepsis is generally divided into early onset versus late onset sepsis. Ze Late Onset Seps “Infection is called early onset sepsis |__ occurs in first week (within 7 days) of life. = Organisms prevalentin tne maternal) & Organisms thriving in the external genital tact or in the delivery area, environment ofthe home or the hospital, includes includes © Group B Streptococcus © Group B Streptococcus © E.coli © Steph. Aureus | © Listeria monocytogenes © Pseudomonas © Ecoli o Candida __after frst week (after 7 days) of fe Infection is called late onset ifit curs Presentation Predisposing | = factors “F” Manifests as pneumonia and less LBW. % Prolonged rupture of membranes ‘Foul smelling liquor | Multiple per vaginal examinations Maternal fever % Difficult or prolonged labor and Aspiration of meconium ‘commonly as septicaemia or meningitis | rr ‘The presentation is that of sepleaemia, pneumonia or meningitis Lew am Lack of breastfeeding Poor cord care ‘Superficial infections (pyoderma, umbilical sepsis), aspiration of feeds, Disruption of skin integrity with needle pricks and use of intravenous fluids ‘+ Investigation: Glinical features: Refusal to feed Lethargic and unresponsive Poor ery Hypothermia and cold clammy skin. Breathing problems (apnea) Diarrhea and vomiting Fast breathing, chest retractions and grunt indicate pneumonia Seizures, neck retraction or bulging anterior fontanel are suggestive of meningitis, ‘Shock, bleeding and renal failure are indicators of overwhelming sepsis C-reactive protei Lumbar puncture ~ more than 1 mg/dL. -WBC <5,000 or >40,000, a total neutrophil count below 1,000, ------most definitive diagnostic test done only when meningitis suspected Neonates with organ-specific signs and symptoms will need additional testing (e.g., chest/abdominal radiographs) > Treatment: ° ° General measures: + UN Fluids «Electrolyte balance * Nutritional support ‘+ Maintenance of temperature ‘Specific measures: «Appropriate antibiotic for 7-10 days or until cultures are negative + If no evidence of meningitis. ampicillin and gentamycin + Ifmeningitis or diagnosis is possible: ampici (Cofotaxime) and third-generation cephalosporin Scanned with CamScanner Deafness Chorioretinits, Microcephaly and mental retardation ‘Anemia, thrombocytopenia and skeletal abnormalities, 1. Congenital Toxoplasmosis Definition ‘Toxoplasmosis isa parasitic disease caused by Toxoplasma gondi ‘+ infected during pregnancy, a condition known as congenital toxoplasmosis may atfect the | |__ chil ai ‘Transmission | Most common route of infection in fans infection in mother during pregnancy, % Most common route of infection in mothers is fecal contamination of hands and eating contaminated undercooked food. Or soil contamination with cat faces _ Clinical features | IUGR | Anemia Jaundice | Hepatosplenomegaly Lymphadenopathy | Classic triad of triad of hydrocephalus, intracranial calcifications, and chorioretinitis. Outcomes: Psychomotor retardation Seizure disorder Visual impairments : Diagnosis Positive toxoplasma IgM in serum ofthe afected chi Prenatal diagnosis: identification ofthe organism in cultures of amniotic fuid, serological testing ‘Treatment/Preve | & Maternal treatment with spiramycin during pregnancy reduces the IKelhood of ranemission ntion significantly Infants are treated with pyrimethamine, sulfadiazine, and leucovorin for one year. oa 2. Congenital Syphilis Definition Congenital syphilis is a severe, disabling, and offen ife threatening infection seen in infants Transmission Transplacental transmission may occur anytime during pregnancy, usually during second half of gestation Clinical features Early (birth2 yrs) ‘© Shuffies ((mucopuruient rhinitis), maculopapular rash (including palms of soles, desquamates), jaundice, periosttis, osteochondritis, chorioretnitis, congenital’ nephrosis, Late (22 years of age): © Hutchinson teeth Clutton joints, saddle nose, osteochondritis, hagades (thickening ‘and fissures of corners of mouth) Syphilis is the only maternal infection that is associated with recurrent abortions ‘Treponema in scrapings (most accurate test from any lesion or fui, serologic tests Most helpful specific esis IgM-FTA-ABS (immunoglobinfuorescent treponemal antibody absorption): but itis not always positive immediate Penicilin Scanned with CamScannerIReView of Pediatrics a | 3. Congenital Rubella * 4 Hepatosplenomegal Definition *F Congenital abla a condon Waterco nanan woke Mahes nected wae Ti that causes German measles. ‘ving ransmission | €Congentalinfecion may occu at anytime during pregnanay Clinical = The fetus is completely spared if infection occurs beyond 16 weeks: | features % The classic findings of cataracts, deafness, and heart defects (PDA) Bluebery muffin spots (extra medullary hematopoiesis), Trromboeytopenia Outcomes: Hearing los, Persistent grow retardation, Microcephaly, Mental and motor rtardat Diagnosis ‘Maternal antibody titers di pregnancy a + After birth, the infant maybe ested forthe vis, rubella specific lM, or persistently eleva Plevateg TreatmentPrev ention ¥ * rubella spect gG “There is no specie Weatment for congenial rel. ‘unequivocal agnosis of ubeliin he rat tiesto of pregnancy is an indication f termination of pregnancy maternal Vaccinating al children and particularly all adolescent gis against ubelais strongly recommended 4. Congenital Cytomegalovirus Definition Transmission a} Condition that can occur wien an infantis infected wth a vis called oyomenaiovius (oyq ‘Transmission anytime during the pregnancy or through exposure to maternal fluids durimse birth (including breast milk). latter Transmission rate significantly higher ifthe mother acquires the disease during pregnancy Transmission possbe even when the pimary mama infecton occured years belong pregnane Clinical ‘% Periventricular calcifications~-characteristic finding features % Chorioretinitis ‘© Microcephaly ‘© Hepatosplenomegaly, jaundice 4 Intrauterine growth retardation Thrombocytopenia, hemolytic anemia ‘Outcomes “_ Sensorineural hearing loss, Neuromuscular abnormalities, Mental retardation Diagnosis + First 2 weeks of ife-——-CMV detected in the urine (saliva, blood) within the fst 2 wk. of We ie consistent with congenital infection ‘+ Inbabies older than 2 weeks, a positive quantitative CMV PCR is the method of choice. TreatmentiPrev | % Supportive car ention Ongoing trials with gancyclovir 5. Herpes Simplex Definition “Congenital herpes simplex is a viral infection caused by exposure in the uterus from HSV. Transmission | ¢ Perinatal infection acquired through exposure to organism in maternal genital tract during delivery. Transmission Infants may also become infected through contact with herpetic breast lesions while feeding or from maternal oral secretions after birth Clinical Three forms of disease have been described; features ‘0. Isolated mucocutaneous lesions (skin, eye, and/or mouth), including keratoconjunctivitis o Encephalitis (0 Disseminated disease involving multiple organs (lungs, liver, often CNS) ‘Outcomes Local disease: Recurrent mucocutaneous lesions Encephalitis: Cataracts/blindness; microcephaly; developmental delay/learning disabilities “Disseminated disease: Severe neurologic impairment, death (50%) Diagnosis % Tzanck smear of the skin lesions, i Si & Culture or PCR for the virus from lesions or from CSF. TreatmentPrev |< Intravenous acyclovir ention ‘Deliver infants by C-section if genital lesions are present at the start of labor. Scanned with CamScannerChesca Jaundice Neonatorum O! Definition onatal Jaundice Nee / * * © Neonatal Jaundice is yellow discoloration ofthe in, mucous membranes, and sciéee. In neonates, jaundice becomes cinicaly apparent when serumrBnraBTrTevels are >S mld. + Physiology: ‘© Bilirubin is a bile pigment, formed from the degradation of heme derived from red blood cell (RBC) destruction and ineffective erythropoiesis, “$y, > gH alzunconugatestorm must be conugetes inthe veto permit excretion in (oie) « « and Etiology: ‘ — Physiological jaundice Pathological jaundice __| Definition | = This term describes the benign and sell. | This term describes jaundice that is secondary limited indirect hyperbilinabinemia that to a pathophysiologic cause and it may be Typically resolves by the end of the first further classified as follows. week of life and requires no Weatment.— © Indirect hyperbilubinemia ©. Direct hypersirubinemia (always jical) Causes [= 1 jinubnload on hepatoavies | Delayed actvty ofthe hepatic enzyme © Sepsisinfectons utter raneterase 3 ABOFRH ncompatalty 2 Inborn errors of metabolism (e.9. hypothyroidism) © Cigle-Naljar syndrome © Gilbert's disease © Hereditary Spherocytosis © Pyruvate kinase deficiency + Direct nyperbiliubinemia © Obstructive jaundice (secondary to ‘© Choledochal eyst& biiary atresia Hepatitis A.B, C Criteria | Clinically jaundice appears after 24 hrs. of age | Clinical jaundice appearing in the first 24 hours Peak birubin fses < 73 mglal Peak birubin rises > 13 mgid Rate of bilirubin rise < 5 mg/dLiday Rate of bilirubin rise > 5 mg/dLiday Clinical jaundice disappear by 1 week in term | Clinic iundice persists for more than 1 week in and 2 weeks in preterm infant. term and 2 weeks in preterm infant. Indirect (Unconjugated) Hyperbilirubinemia % Definition ‘© Increased indirect bilirubin either Due to | production of unconjugated bilirubin from hemolysis or due to | uptake or conjugation of unconjugated biirubin ‘©. Can be physiological or pathological ‘+ Differential diagnosis of indirect hyperbilirubinemia ‘© Physiological jaundice Breastfeeding jaundice Breast mik jaundice Sepsis disease) Increased RBC load from bruising (e.g. Cephalohematoma, Birth trauma) Increased bilirubin from hemolytic disease of the newborn (e.g. ABO-Rh incompatibility, ‘Spherocytosis, Gépd deficiency & Pyruvate Kinase Deficiency) Inherited disorders of bilirubin uptake and conjugation (e.g. Crigler-Najjar syndrome, Gilberts Scanned with CamScanner ee = ee e Se e e é é é é 4 « « 4 t