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Addendum: Pediatrics Review

WHO 2009 Classification


Dengue without warning signs: Live in/travel to endemic areas Fever and 2 of the ff criteria: 1. Nausea, vomiting 2. Rash 3. Aches & pains 4. Tourniquet test positive 5. Leukopenia

WHO 2009 Classification


Dengue with warning signs: 1. Abdominal pain or tenderness 2. Persistent vomiting 3. Clinical fluid accumulation 4. Mucosal bleed 5. Lethargy, restlessness 6. Liver enlargement > 2 cms 7. Increase in hct with decrease in platelet

WHO 2009 Classification


Severe dengue: 1. Severe plasma leakage Shock (DSS) Fluid accumulation with respiratory distress
2. Severe bleeding As evaluated by clinician

WHO 2009 Classification


3. Severe organ involvement liver: AST or ALT >1,000 CNS: impaired consciousness Heart and other organs

Dengue Fever
Dengue NS-1 Ag Day 1 and Day 4 of the illness

Rickets
Disease of growing bone which occurs in children only before fusion of the epiphyses Due to unmineralized matrix at the growth Increase in the circumference of the growth plate and the metaphyses --> widening of the wrists & ankles General softening of the bones

Rickets
Craniotabes or softening of the cranial bones Widening of the costochondral junctions leads to rachitic rosary Harrison groove is a horizontal depression along the lower anterior chest due to pulling of the softened ribs by the diaphragm during inspiration

La Leche League International


All milk should be dated before storing. Preferably, human milk should be refrigerated or chilled right after it is expressed. Guidelines for storing human milk: 1. At room temperature (19-26 C) for 4 hours (ideal), up to 6 hours (acceptable) 2. In a ref < 4 C for 72 hrs (ideal), up to 8 days (acceptable)

LLLI
3. In a freezer (-18- -20 C) for 6 months (ideal), up to 12 months (acceptable) . What type of container should be used? 1. Glass or hard-sided plastic containers with well-fitting tops 2. Containers not made with the controversial chemical bisphenol A (BPA) 3. Containers which have been washed in hot, soapy water, rinsed well, and air-dried

LLLI
4. Containers should not be filled to the top leave one inch of space to allow for expansion 5. Put only 2-4 ozs of milk in the container to reduce waste. 6. Disposable plastic bags are not recommended as it leads to greater risk of contamination.

How to warm the milk:


1. Do not refreeze thawed milk. 2. Previously frozen milk that has been thawed can be kept in the refrigerator for up to 24 hrs. 3. Frozen milk: thaw in the ref overnight or under cool running water 4. Refrigerated milk: under warm running water for several minutes. Do not heat the milk directly on the stove. Do not use microwave.

Guidelines on Infant & Young Child Feeding


UNICEF & WHO recommend that infants be exclusively breastfed on demand for the 1st 6 months of life Early introduction of food & other liquids? 1. Reduces breast milk intake 2. Decreases full absorption of nutrients from breast milk 3. Increases the risk of diarrhea and URI

Febrile Seizures
Most common seizure disorder in childhood Rare before 9 months and after 5 yrs old Peak age of onset: 14-18 months old Normal neurologic exam Normal EEG (+) family history

Comparison:
Simple: Lasts a few secs & rarely >15 mins. Initially generalized and tonic-clonic Followed by a brief period of post-ictal drowsiness Occurs only once in 24 hrs Complex: Duration is >15 mins. Repeated convulsions occur within 24 hrs Focal seizure activity

Status Epilepticus
One seizure lasting 30 mins or multiple seizures during 30 mins without regaining consciousness Usual cause: breakthrough seizures missed doses of anti-epileptic drug/s May be due to CNS infection

Persistent Pulmonary Hypertension of the Newborn


Failure of the normal circulatory transition that occurs after birth Syndrome: marked pulmonary hypertension that causes hypoxemia and right-to-left extrapulmonary shunting of blood With inadequate pulmonary perfusion, neonates are at risk for developing refractory hypoxemia, respiratory distress, and acidosis.

PPHN
Most common cause is meconium aspiration syndrome about 13% of all live births are complicated by meconium-stained fluid but only 5% who had this complication subsequently develop MAS Coarse streaking granular pattern in both lung fields Irregularly aerated lungs Flattened diaphragm, increased AP diameter

PPHN
2nd most common cause is idiopathic black-lung Significant remodeling of pulmonary vasculature with vascular wall thickening and smooth muscle hyperplasia Contributory factor: use of NSAIDs during 3rd trimester leading to constriction of the fetal ductus arteriosus in utero

SMR in Boys
SMR Stage PUBIC HAIR 1 None 2 Scanty, long, slightly pigmented

PENIS Preadolescent
Slight enlargement

TESTES Preadolescent
Enlarged scrotum, pink, texture altered Larger

Darker, starts to curl, small amount Longer 4 Resembles adult type but less in quantity; coarse, curly Larger; glans and breadth increase in size 5 Adult distribution, spread to medial surface of thighs Adult size

Larger, scrotum dark Adult size

SMR in Girls
SMR STAGE PUBIC HAIR BREASTS

1
2

Preadolescent
Sparse, lightly pigmented, straight, medial border of labia

Preadolescent
Breast and papilla elevated as small mound; areolar diameter increased

Darker, beginning to curl, increased amount


Coarse, curly, abundant but amount less than in adult Adult feminine triangle, spread to medial surface of thighs

Breast and areola enlarged, no contour separation


Areola and papilla form secondary mound Mature, nipple projects, areola part of general breast contour

4 5

Gross motor skills


6 years old skip
8 years old hop on one foot twice, then the other

Fine motor skills


6 years old- tie shoe laces
7 years old- print letters, letter reversal

8-10 years old rapid alternating


movement of the hand, cursive writing 10-12 years old manipulative abilities similar to adult

Social development
Expanding social world
Identification and reliance on peer groups 7 years attachment to parents decrease and to peers increase 9 years tightly knit groups are formed;

group loyalty and commitment to


best friends

Social development 4-5 y/o


Toilet-trained Plays imaginary games Helps in tasks in house Cooperative group play: takes turns and shares Tender and protective Cooperative most of the time Chooses own friends

Emotional development 4-5 yrs old


Make-believe games Toy guns are simply an innocent and entertaining way to be competitive and to boost their self-esteem (Shelov, 1994). Interest in basic sexuality May play with their genitals ---- signs of normal curiosity! Do not scold or punish! Be straightforward

Emotional development: 4-5 yrs old


Parents should answer in simple and correct terms. Parents should tell their child not to let other person touch the private parts. Teach your child not to talk to strangers. Teach childs name, address, phone if lost. Normal for a 4 year old to make up stories. Encourage child to sleep in own bed.

APGAR Score
What is the order of disappearance in a sick baby? Color Respiration Muscle tone Reflex Cardiac rate

APGAR Score
What is the order of appearance in a resuscitated baby? Cardiac rate Color Respiration Reflex Muscle tone

Essential Intrapartum Newborn Care


Immediately after birth: dry the baby to stimulate breathing & to avoid hypothermia Delay cord clamping 2-3 minutes after birth or until the cord has stopped pulsating (less occurrence of IVH and anemia in terms & preterms)
***clamp the cord without milking it 2 cms from the base & put the
2nd clamp 5 cms from the base and cut the cord

Essential Intrapartum Newborn Care


Early skin-to-skin contact: place the baby on mothers chest or abdomen 1. to provide warmth 2. to increase the duration of breastfeeding 3. to allow the good bacteria from the mothers skin to infiltrate the newborn (prevents hypoglycemia)

Essential Intrapartum Newborn Care


Washing should be delayed until after 6 hours of life because this removes the vernix, thus exposing the newborn to hypothermia. Non-separation of mother and newborn for breastfeeding: 20-60 minutes after birth

Newborn Care
Eye prophylaxis Erythromycin ointment 0.5% or tetracycline ointment 1% Vitamin K: 1 mg IM Vaccine: Hepatitis B and BCG

Newborn Screening Test


Congenital hypothyroidism Congenital adrenal hyperplasia Galactosemia Glucose 6-phosphate dehydrogenase deficiency Phenylketonuria

Newborn Screening Test


RA #9288 Done at 48 hours old If blood was collected <24 hours old, repeat at 2 weeks old.

Congenital Hypothyroidism
Normal birth weight & length Delayed physical, mental & sexual development Sluggish, feeding difficulties, hypothermia Edema of scrotum / genitals Prolonged physiologic jaundice

Congenital Adrenal Hyperplasia


Deficiency of 21-hydroxylase enzyme: deficiency of cortisol Normal at birth but signs of sexual & somatic precocity appear within the 1st 6 months of life Vomiting, failure to thrive

Galactosemia
3 distinct enzyme deficiencies: 1. galactose-1-phosphate uridyltransferase deficiency (GALT) - classic form 2. Galactokinase deficiency (GALK) 3. Galactose-4-epimerase deficiency (GALE) Injury to parenychymal cells of the kidneys, liver & brain Feeding intolerance, vomiting, jaundice, convulsions, lethargy, hypotonia, mental retardation

G6PD deficiency
Episodic or chronic hemolytic anemia Episodic: symptoms develop 1-2 days after exposure to a substance with oxidant properties: sulfonamides, nalidixic acid, nitrofurantoin, chloramphenicol, antimalarials, vitamin K analogs, ASA, benzene, naphthalene

G6PD deficiency
Onset of hemolysis results in precipitous fall in Hgb & Hct Heinz bodies Reticulocytosis Jaundice, anemia, hemolysis, acute renal failure

Phenylketonuria
Deficiency of the enzyme phenylalanine hydroxylase causes accumulation of pheynylalanine in body fluids (hyperphenylalaninemia) Excess phenylalanine is transaminated to phenylpyruvic acid or decarboxylated to phenylethylamine & disrupts normal metabolism & cause brain damage

Phenylketonuria
Affected infant is normal at birth Most common manifestation without treatment is developmental delay MR develop gradually Infant: severe vomiting, hypertonic, hyperactive DTRs, seizures; older: hyperactive with purposeless movements, rhythmic rocking & athetosis unpleasant musty odor

Neonatal Jaundice
Physiologic
presents after the 48th hour of life TB increases not > 5 mg/dL/day TB peaks at 14-15 mg/dL DB < 10% of TB resolves in 1 week (term), 2 weeks (preterm)

Pathologic
presents in the 1st 24 hours of life TB increases by > 0.5 mg/dL/hr TB increases to > 15 mg/dL DB > 10% of TB persists beyond 1 week (term), 2 weeks (preterm)

Jaundice related to breastfeeding


Breastfeeding jaundice: Onset at 3-4 DOL; 13% of breastfed infants Accentuated unconjugated hyperbilirubinemia Factors: decreased milk intake with dehydration; reduced caloric intake Duration is a few days Breast milk jaundice Onset after 7th DOL Increased B1 in 2% of breastfed term infants As high as 10-30 mg/dL during the 2nd-3rd week Factors: presence of glucuronidase in some breast milk Duration: 3 weeks to 3 months

Jaundice related to breastfeeding


To reduce incidence of breastfeeding jaundice: Frequent breastfeeding (>10/24 hrs) Rooming-in with night feeding Discouraging 5% dextrose or water supplementation Ongoing lactation support

Breast milk jaundice: If breastfeeding is continued, bilirubin gradually decreases but may persist for 3-10 weeks at lower levels. If discontinued, serum bilirubin level falls rapidly. Phototherapy may be of benefit.

Small for Gestational Age


also known as intra-uterine growth retardation (IUGR) BW is < 3rd percentile for calculated gestational age growth of the fetus affected by fetal, uterine, placental and maternal factors increased morbidity and mortality

IUGR
Symmetric - earlier onset & associated with diseases that seriously affect fetal cell number like chromosomal, genetic, malformation, teratogenic, infectious, or severe maternal hypertensive etiologies Asymmetric - late onset & associated with poor maternal nutrition or with late onset or exacerbation of maternal vascular disease

Large for gestational age


maternal diabetes & obesity are predisposing factors maternal hyperglycemia leads to fetal hyperglycemia & hyperinsulinism SSx: hypoglycemia, plethora increased risk of: respiratory distress syndrome
congenital cardiac defects lumbosacral agenesis hyperbilirubinemia

Post-term infants
Born after 42 wks of gestation regardless of birth weight Unknown cause Their appearance & behavior suggest those of an infant 1-3 wks of age Absence of lanugo & vernix caseosa, long nails, abundant scalp hair, desquamating skin & increased alertness CS may be indicated for older primigravidas who go more than 2-4 wks beyond term

Respiratory Distress Syndrome


due to deficiency or immaturity of surfactant
increased surface tension causes alveolar collapse & V/Q mismatch & hypoxia

seen in preterms incidence is inversely proportional to gestational age (60-80% in <28 wks of gestation) SSx: respiratory distress soon after birth CXR: ground-glass pattern, air bronchograms prevention: reach term, maternal steroids at least 48 hrs prior to delivery

RDS (Hyaline Membrane Disease)


Risk factors: Maternal diabetes Multiple births Cesarean section delivery Precipitous delivery Asphyxia Cold stress History of previously affected infants

RDS
Tx: supportive (most are self-limited), mechanical ventilation for severe RDS & persistent apnea (to improve oxygenation & elimination of CO2 without causing pulmonary barotrauma or 02 toxicity), exogenous surfactant complications: pneumothorax
IVH persistent PDA bronchopulmonary dysplasia (bubbly lungs or cystic lucencies, irregularly aerated lung)

ABO incompatibility
Most common cause of hemolytic disease of the newborn Occurs in 20-25% of pregnancies but hemolysis develops in only 10% of such offspring Mother is type O and baby is either A or B Most cases are mild; jaundice Mild hepatosplenomegaly Phototherapy

RH incompatibility
Rh antigenic determinants are genetically transmitted from each parent & direct the production of blood group factors (C, c, D, d, E, e). Each factor can elicit a specific antibody response where 90% are due to D antigen. Rarely occurs during the 1st pregnancy because transfusion of Rh+ fetal blood into an Rh- mother occurs near the time of delivery, too late for the mother to become sensitized & transmit antibody to her infant before delivery.

Mnemonics:
For infants < 6 months old: Wt in grams = age in months x 600 + birth weight For infants 6-12 months old: Wt in grams = age in months x 500 + birth weight For 1-6 years old: Wt in kilos = age in years x 2 + 8

Length / Height:
Birth to 3 months 4-6 months 7-9 months 10-12 months 9 cm 8 cm 5 cm 3 cm

Height in cm = Age in years X 5 + 80 Height in inches = Age in years X 2 + 32

Length / Height:
At 1 year
2 years

30 inches
1/2 of mature height

3 years
4 years 13 years

3 feet tall
40 inches or 2x the birth length 3x the birth length

Head circumference:
at birth = 14 inches (13.5-14.5) 33-35 cm
- routinely taken up to 3 years old - approximates adult head circumference at 6 years old - measured over the glabella and supraorbital ridges anteriorly and part of the occiput which gives the maximal circumference posteriorly

Average increase in head circumference:


Age Increase Total First Year 1st 4 mos. 1/2 in/mo 2 inches Next 8 mos. 1/4 in/mo 2 inches ______________________________ Second Year 1 in 1 in ______________________________ 3-5 Years 1/2 in/year 1.5 inches ______________________________ 6-20 Years 1/2 in/5 yrs 1.5 inches

Chest circumference:
- measured at mid-respiration at the level of the xiphoid cartilage or substernal notch - measured in recumbent position for infants

More mnemonics:
1st part of infancy Chest circumference < Head circumference
- Middle part of infancy CC = HC - Latter part CC > HC Number of teeth = Age in months - 6

Growth characteristics:
First Year - 10% decrease in birth weight in the 1st week - Birth weight regained or exceeded by 2 weeks - Gain of 30 g/(1 oz) day in the 1st month - Gain of 20 g/day beginning the 3rd or 4th month - Eruption of 1st tooth - mandibular central incisors

More changes in 2-5 years old:


physical energy peaks, need for sleep declines (11-13 hr/24 hr) VA of 20/20 at 4 years old all primary teeth have erupted by 3 years old

School age (6-12 years old):


gain of 3-3.5 kg (7 lb) and 6 cm (2.5 in) per year head increases by 2-3 cm in the entire period = slowed brain growth myelinization is complete by 7 years old stable body habitus

School age (6-12 years old):


growth of mid-face and lower face occurs gradually loss of deciduous teeth beginning at age 6 years (replaced with adult teeth at about 4/year) lymphoid tissues hypertrophy = impressive tonsils and adenoids muscular strength, stamina and coordination increase progressively

Water requirements
Normal infants absolute water requirement is 75-100 ml/kg/24 hrs 0-6 mo: 700 ml/24 hrs 7-12 mo: 800 ml/24 hrs 1-3 yrs old: 1,300 ml/24 hrs 4-8 yrs old: 1,700 ml/24 hrs

Scurvy
Vitamin C deficiency early symptoms: lowgrade fever, irritability, tachypnea, anorexia, generalized tenderness esp. in the legs Pseudoparalysis with hips & knees semiflexed & the feet rotated outward scorbutic rosary at the costochondral junction & depression of the sternum Angulation of the scorbutic beads is sharper than the rachitic rosary

Scurvy
Bluish, purple spongy swellings of the mucous membranes esp. over the upper incisors Other symptoms: swollen joints, purpura and ecchymoses, poor wound & fracture healing, perifollicular hemorrhages X ray changes: distal ends of long bones with a ground-glass appearance Plasma ascorbate of <0.2 mg/dL is deficient

Treatment for scurvy


Daily intake of 3-4 oz of orange or tomato juice
Vitamin C supplements of 100-200 mg orally or parenterally are preferable to ensure more rapid and complete cure.

Larger doses (>2 grams) may produce abdominal pain and osmotic diarrhea

Contraindications to Breastfeeding
1. 2. 3. 4. 5. 6. 7. Infants with galactosemia Mothers with: Septicemia Active TB Breast cancer Malaria Typhoid fever Substance abuse Severe neurosis or psychosis

Breastfeeding
Acute maternal infection may contraindicate breastfeeding IF the infant does not have the same infection. When the infant is unaffected, the breast may be emptied and the milk be given by cup or bottle. Mastitis usually can be alleviated by continued and frequent nursing on the affected breast to keep it from becoming engorged (warm compress).

Breastfeeding
Transmission of HIV by breastfeeding is well documented. If safe alternatives are available, breastfeeding by HIV-infected mothers is not recommended. In many developing countries, breastfeeding may be crucial for infant survival. WHO recommends that breastfeeding be continued unless safe infant formula is readily available.

Breastfeeding
CMV, rubella virus, hepatitis B virus, human T-cell lymphotropic virus type 1, & herpes simplex virus have been demonstrated in breast milk. Evidence of breast milk transmission of other viruses is rare. Although hep B virus has been isolated from breast milk, the predominant means of mother-infant transmission appears to be through delivery.

Leukemias
Most common malignant neoplasm in childhood (41% of all malignancies that occur in <15 years old) ALL (77%) AML (11%) CML (2-3%) - Philadelphia chromosomal translocation JCML (1-2%)

Leukemias
Group of malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to an unregulated clonal proliferation of cells Increased rate of proliferation & decreased rate of spontaneous apoptosis Result: disruption of normal marrow function

Acute Lymphoblastic Leukemia


malignant proliferation of lymphoblasts most common childhood malignancy peak incidence 2-6 yrs old; M>F unknown etiology increased incidence in:
Down Syndrome, ataxia-telangiectasia, Fanconi syndrome, neurofibromatosis type 1 risk is >70% if the first twin is diagnosed during the 1st year of life and they shared the same placenta patients who have undergone intense Tx for a solid tumor

Other ALL risk factors:


Exposure to medical diagnostic radiation during in utero and in childhood Drugs, alkylating agents Nitrosurea Benzene exposure Advanced maternal age

ALL
SSx: (acute onset < 4 wks duration of Sx) non-specific (anorexia, irritability, lethargy)
signs of marrow failure (anemia, bleeding, purpuric/petechial lesions, low-grade fever) signs of infiltration (bone pain, lymphadenopathy,
splenomegaly > hepatomegaly)

ALL
Dx: bone marrow aspiration
anemia, thrombocytopenia (75%), lymphoblasts in the PBS & bone marrow, median WBC count is 33,000 CXR may show a mediastinal mass CSF may contain lymphoblasts (10-20%)

Diagnosis
ALL is diagnosed by a bone marrow evaluation that shows >25% of the BM cells as a homogenous population of lymphoblasts Differential dx: infectious mononucleosis (acute onset of fever and lymphadenopathy) and JRA (fever and joint swelling)

Prognostic / predictive factors:


The single most important prognostic factor in ALL is the treatment.
3 of the most important predictive factors: Age of the patient at the time of diagnosis Initial leukocyte count Speed of response to treatment Average risk: age between 1-10 yrs old and leukocyte count of <50,000/uL

1. 2. 3.

ALL
no anatomic staging system because usually disseminated at the time of Dx Tx:
remission induction (vincristine, prednisone, Lasparaginase x 4 wks + CNS prophylactic irradiation or chemotherapy) to eradicate leukemic cells from BM consolidation phase: 14-28 wks to prevent later CNS relapse maintenance phase x 2-3 years (Mercaptopurine daily and Methotrexate weekly)

complication of treatment: tumor lysis syndrome

Treatment
Remission defined as <5% blasts in the BM and a return of neutrophil and platelet count to near-normal levels after 4-5 wks of tx RELAPSE occurs in the BM in 15-20% of patients with ALL -- BAD! esp. if it occurs during or shortly after the tx Options: intensive tx with agents not previously used followed by allogenic stem cell transplantation results in long-term survival rate for a few patients

ALL
sites of relapse: bone marrow, CNS (increased ICP and isolated cranial nerve palsies), testes (painless swelling of one or both testes in 1-2% of males) poor prognostic factors:
< 2 yrs or > 10 yrs male WBC > 100,000 u/L on presentation presence of CNS leukemia presence of a mediastinal mass

Comparison:
Osteosarcoma: 2nd decade; M>F All races Spindle-cell producing osteoid Metaphysis of long bones Local pain & swelling, often history of injury Sunburst pattern Spreads to lungs, bones Chemotx and ablative surgery of primary tumor Ewing tumor: 2nd decade: M>F Primarily whites Undifferentiated small round cell of neural origin Diaphysis of long bones Local pain & swelling with fever Onion-skinning Spreads to lungs, bones Chemotx, radiation and/or surgery of primary tumor

Type

Description

Cause

Obstructive or Obstruction Abnormality of the noncommuni- within the ventri- aqueduct or a lesion in cating cular sytem the 4th ventricle (aqueductal stenosis) Nonobstruc- Obliteration of Follows a tive or the subarachsubarachnoid hemorrcommunica- noid cisterns hage ting Malfunction of the arachnoid villi Leukemic infiltrates

Febrile Seizure
Most common seizure disorder in childhood Rare before 9 months and after 5 yrs old Peak age of onset: 14-18 months old Normal neurologic exam Normal EEG (+) family history

Comparison:
Simple: Lasts a few secs & rarely >15 mins. Initially generalized and tonic-clonic Followed by a brief period of post-ictal drowsiness Occurs only once in 24 hrs

Complex: Duration is >15 mins. Repeated convulsions occur within 24 hrs Focal seizure activity

Summary of Neurocutaneous syndromes


Syndrome Manifestations Neurofibro -matosis (Von Recklinghausen) Tuberous Sclerosis PE finding Diagnos- Treattics ment
Genetic counseling & early detection of treatable complications Seizure control; multi-disciplinary approach Caf au lait Axillary or CT scan or macules that inguinal MRI spare the face freckling, Lisch nodules, optic glioma Multisystemic; Seizures, mental retardation Tubers in cerebrum (candledripping); ash leaf shagreen CT scan or MRI of the brain, heart, abdomen; 2D echo; renal UTZ

PEDIATRIC PULMONOLOGY

Bronchial Asthma
a reversible obstructive airway disease involving both the small & large airways
increased residual lung volumes decreased FEV1/FVC ratio

3 components of an asthma attack:


bronchospasm mucus production airway edema

Bronchial Asthma
SSx: family Hx of asthma or atopy, recurrent cough & wheezing with exposure to certain triggers (viral infection, weather changes, exercise, allergens, emotions), responds to Tx with bronchodilators CXR: hyperinflation; helps to exclude structural abnormalities of the airway or chronic infection

Bronchial Asthma
Pulmonary function tests: increased residual lung volumes, decreased FEV1/FVC ratio Not routinely done esp. for <5 yrs old due to inability of these children to perform reproducible expiratory maneuvers

Exacerbation of asthma:
Acute or subacute deterioration in symptom control that is sufficient to cause distress or risk to health Any of the following: Increase in wheeze or shortness of breath Increase in coughing, esp. at night Lethargy or reduced exercise tolerance Impairment of daily activities Poor response to reliever medication

Management:
Management of acute attacks:
short-acting inhaled beta2-agonist oral or IV steroids (Prednisolone) anticholinergics (ipratropium bromide) never used alone methylxanthines (theophylline, aminophylline) - NOT first line

Management in between attacks:


inhaled corticosteroids long-acting inhaled beta2-agonist leukotriene modifiers (Montelukast)

Levels of asthma control


Characteristic
Daytime symptoms

Controlled (all Partly of the following) controlled (any


measure present in any week)

Uncontrolled (3 or more
of features of partly controlled asthma in any week)

None (less than 2x/ wk)

More than 2x/wk

More than 2x/wk (last minutes or hours or recur) Any (may cough, wheeze during exercise, vigorous play, or laughing)

Limitation of activities

None (fully active)

Any (may cough, wheeze during exercise, vigorous play, or laughing)

Levels of asthma control


Characteristic
Nocturnal symptoms or awakening

Controlled (all Partly of the following) controlled (any


measure present in any week)

Uncontrolled (3 or more
of features of partly controlled asthma in any week)

None (no nocturnal coughing during sleep)

Any (typically coughs during sleep or wakes with cough, wheezing, and/or dyspnea) > 2 days/week

Any (typically coughs during sleep or wakes with cough, wheezing, and/or dyspnea)

Need for reliever / rescue treatment

2 days/week

> 2 days/week

Initial Assessment of Acute Asthma


Symptoms
Altered consciousness

Mild
No

Severe
Agitated, confused, or drowsy Less than 90%

Oximetry on presentation (Sa02)

Equal or more than 94%

Talks in sentences/words sentences

words

Initial Assessment of Acute Asthma


Symptoms
Pulse rate

Mild
< 100 bpm

Severe
>200 bpm (0-3 yrs) >180 bpm (4-5 yrs) Likely to be present

Central cyanosis

absent

Wheeze intensity

variable

May be quiet

How to use table


Any of the severe symptoms indicate a severe asthma exacerbation Oximetry performed before administration of oxygen or bronchodilator

Pulmonary Tuberculosis
Mycobacterium tuberculosis Most specific confirmation is isolation of the organism! Sputum specimens for culture for those who can expectorate Induce sputum with a jet nebulizer & chest percussion followed by nasopharyngeal suctioning: for culture and smear staining

PTB
Gastric aspirates: cultured Young children: early AM gastric acid obtained before the child has arisen & peristalsis has emptied the stomach of the pooled secretions 3 consecutive AM gastric aspirates yield the organism in <50% of cases

Pulmonary Tuberculosis
1. 2. 3. 4. Primary complex (Ghon complex): Primary pulmonary focus Regional lymph nodes Peritracheal lymph nodes Localized pleurisy between the middle & lower lobes

Diagnostic Criteria for PTB:


Exposure to TB sputum (+) adults (+)PPD test Signs & symptoms (any 2 or more) Chest X ray findings Isolation of the organism

Signs and symptoms:


Cough w/ or w/o wheezing for > 2 wks Unexplained fever for > 2 wks Failure to gain weight; weight loss Unexplained poor appetite Painless cervical lymphadenopathy Failure to respond to 2 wks appropriate antibiotic therapy for LRTI

Classification:
Class I: TB exposure: (+) exposure to and adult/adolescent with active disease, (-) PPD, no signs/symptoms, negative chest x ray findings
Class II: TB infection: +/- exposure, (+) PPD, no signs/symptoms, negative chest x ray findings

Classification:

1. 2. 3. 4. 5.

Class III: TB disease: 3 or more of the ff criteria: Exposure to an adult/adolescent with active TB disease (+)PPD Signs/symptoms suggestive of TB Abnormal chest x ray findings Laboratory findings

Classification:
1. 2. 3. 4. 5. 6. Class IV: TB inactive: w/ or w/o history of previous TB w/ or w/o previous chemotherapy has radiographic evidence of healed/calcified TB (+)PPD no signs & symptoms (-) smear or culture for TB

PPD interpretation:
Equal or >10 mm is (+)
Equal or >5 mm is (+) in the presence of any or all of the ff: 1. history of close contact with a known or suspected case of TB 2. clinical findings suggestive of TB 3. chest X ray findings suggestive of TB 4. immunocompromised condition

Management:
INH 10 mg/kg/day (6 months) Rif 15 mg/kg/day (6 months) PZA 25 mg/kg/day (2 months) Ethambutol 15-25 mg/kg/day (>6 y/o) Streptomycin 20-30 mg/kg/day