PIT FALLS IN PAEDITRIC PRACTICE Prof. Dr. Sharad Agarkhedkar Prof. & HOD Dept. of Paediatrics Dr. D.Y. Patil Med. College Hon. Paediatrician - Sanjeevan Hospital Deenanath Mangeshkar Hospital Sutika Seva Mandir Ordinance Factory Hospital
NEWBORNS Gest age assessment - Weight is not the criteria. There are physical & neurological criteria. Don't forget - “ Not every LBW is Premature “ I.U.G.R.s are more common problems. Separating cord looks shaggy- It's not sepsis. Icterus look at the tip of the nose Face - 5 mg Chest – 10 mg Thighs – 15 mg Palms / Soles – 20 mg Weight loss 15% - Preterms 10% Term babies
Post Neonatal - Jaundice 3 wks – Clay coloured stools of biliary obst. To be diagnosed & operated in 6 wks. Beyond that it's too late. - Post fontanel – closure 2 months if not then think of Hypothyroidism. - Every weeks delay of treatment can cause loss of IQ by 5 points. - Sepsis – with rash – urgency Meningitis – AF bulging in quiet state shrill cry. - Pneumonia – Chlamydia Pneumonia – Macrolides Paraxysmal Cough like whooping cough
Vomiting If yellowish , greenish think of Surgical cause. Vomiting with satisfactory wt gain ignore it. Vomiting with full AF – look for intracranial cause Vomiting with lump in Rt. Hypochondriac region with visible peristalsis CHPS. Projectile vomits with shrill cry – Raised ICP Rule out intracranial lesions ICH, IVH, SOL
Cardiac No murmur at birth. Sudden appearance of murmurs at 2 months indrawing at 4 th ICS with each Heart beat indicates L – R shunt Bounding pulses ? VSD ? PDA Absent pulses – coarctation single 2 nd sound in PA ? T.O.F. - Every murmur is not CHD - No murmur doesn't rule out CHD
Weight gain doubles by 5 months Triples by 1 year Qudruples by 3 yrs. Height 50 cms at birth 75 cms at 1 year 85 cms at 2 year 5 To 7 cms/year thereafter Assess Growth Velocity
HC - 33 – 35 cm at birth Increase 2 cm/ month for 3 months Increase 1 cm/ month 4 – 6 months Increase 0.5 cm / month 6 – 12 months HC > Chest Circumference at birth HC = Chest at 9 months to 1 year CC increase thereafter
DEHYDRATION Wight loss is the best judge Upto 5% No Dehydration Infants - 5 – 10% Some dehydration > 10 % Severe dehydration Older Children > 3% No dehydration > 6% Some dehydration > 9% Severe dehydration
Dehydration difficult to assess in obese & malnourished children - assess pulse rate - assess weight SHOCK IN CHILDREN IS ALWAYS DUE TO DEHYDRATION UNLESS PROVED OTHERWISE.
INTUSUSCCEPTION H/O AGE Screaming Attacks Red current jelly stools Prolapse rectum Sausage ( Banana ) shaped Lump in Para umbilical region Baby becomes quiet in between – Do USG Abdomen
Pulled Elbow 6 months – 2 yrs Three months Colic. Viral Group – Typical History Epiglotitis – Red Epiglottis Torsion Testis Obstructed Hernia Diaper Dermatis
WHEEZE EVERYTHING THAT WHEEZES IS NOT ASTHMA IT COULD BE - * BRONCHIIOLITIS * EVENTERATION * LARYNGOMALACIA * C.H.D. / VASCULAR RINGS * SEVERE AIRWAY OBST. - NO AIR ENTRY AT ALL SILENT CHEST * BAD SIGN – ACT FAST
PUO VIRAL – Conjuctival injection - All mucosae involved - Post Cervical nodes - Macular rash - soft Hepatospleenomegaly - Palatal bleeds ENTERIC – CAECAL GURGLING- - Spleno – Hepatomegaly - Step – ladder pattern - Toxic look 2 nd Week Widal Test – Rising Titres Blood culture in 1 st Week.
URINARY TRACT INFECTION No signs / symptoms Urine Routine - > 10 cells / HPF Culture - > 105 organism / ml Males Screening for renal anomalies MCUG for VUR Malaria - Intermittent fever Firm spleen No rigors
NUEROLOGICAL - Brisk DT Jerks - Upgoing planters - Ankle & patelar clonus Are you thinking of spinal cord lesion ? Yes. But it could be a mere sign of raised ICP. Raised ICP – Think of Cushing's Traid Bradycardia Hypertension Irregular respiration Papilloedema is seen in only 2% of patients with raised ICP.
Pain in Abdomen - Cause can be in Lungs Empyema Lower lobe Pneumonia - Cause can be in skin shigelles ( Herpes ) - Cause can be in Brain Abdominal epilepsy - Cause can be porphyria
Pneumococcal Bacteraemia Age Group – 3 months – 2 years Presentation – Fever, mild cold No positive findings on clinical examination X Ray Chest, Haemogram - normal Eventual localisation – AOM High index of suspicion is necessary Penicillin is the drug of choice.
Uncosolable Crying After DPT High pitched shrill cry Can occure within 7 days max. Always observe & admit if necessary. Hypotensive Hyporesponsive syndrome can occur – Hypoglycaemia is a sign - qua non Rehydration – Dextrose infusion is the treatment.
Todd's Paralysis * Lateralisation after GTC * Hypo / Hypertonia Areflexia / Hyperreflexia Lasts for upto 7 days Recovers on its own. No investigations or treatment required.
Kawasaki Disease * Fever > 5 days * Bulbar conjuctivitis * Cervical Lymphadenopathy * Strawberry tongue * Maculo Papular Rash * Periungual exfoliation * Oedema Hands / Feet * High index of suspicion required * No diagnostic test * Coronary Aneurysin on Echo Treatment – IV IgG, Aspirin Waterloo for Paediatrician