Pitfalls in pediatrics
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Pitfalls in pediatrics






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Pitfalls in pediatrics Pitfalls in pediatrics Presentation Transcript

    • M.D.,D.C.H.,LL . B.
    • Chairman, Medico-legal Cell, IMA,Maharashtra State, & Pune Br
    • and I AP, Maharashtra
  • Pitfalls in Pediatrics: General Principles
    • 1. Failing to keep abreast of changing knowledge and concepts—IVIG in GBS, Anti-microbial pattern in your setting
    • 2. Short- cut histories and physical exams; bus conductor ticket prescriptions
    • 3. Failing to remember the famous dictum- think of common diagnosis, you will be commonly right —and vice versa! e.g. Asthma, TB in chronic cough rather than CF, Cong. Cysts etc.
    • Not revising diagnosis if no +ve result or if further deterioration after reasonable interval. (Call for added opinion)
  • Pitfalls in Pediatrics-History taking:
    • To underestimate any symptom-headache, vomiting, cheat pain
    • To accept other’s  at its face value
    • Forgetting h/o pets, allergy, fb, birth, pica, milestones, consanguinity, immunizations
    • Not to ask history to child directly>3yrs
    • Deficiencies in exam: BP, Throat, Wt., Ears, AF, Head Ò, RR, Teeth, Spine, Femorals, Hips, Perineal area, Anemia, Eyes (cataracts, movements, phlyctene, pupils) Hips, Gait
  • Pitfalls in Pediatrics
    • Failing to refer in time: No one is perfect. Refer to lab/radiologist/expert/institute in time. (A case of pregnancy+vomiting all 9mo.-lady died of s.o.l.; puo etc)
    • Not taking cognisance of the reports you ordered-(overlooking +ve report of urine sugar; m.p.)
    • Relying too much on reports-primary complex-must read in light of clinical s/s
  • Pitfalls in Pediatrics
    • Investigations and Treatment riskier than disease!-brain lesion biopsy in suspected tuberculoma; pleural biopsy in t.b.effusion
    • Tel. Advice on tel. rash diagnosis
    • Not considering f.b.in diff.diagnosis-nose/eye/bronchus/urethra/rectum/esophagus
    • Lack of records-esp.growth & development, vaccination and all relevant records
    • Lack of follow up
  • Pitfalls in Pediatrics
    • Ordering non-specific, hectic measures at terminal moment-analeptics, cardiac massage
    • Over hospitalisation-will spread nosocomial infections
    • Non informing/educating patients about disease/treatment: t.b.; cancer; nephrotic etc.
    • Not imparting preventive advice: vaccines; nutrition; diarrhoeas; addictions; accidents etc;
    • detecting and advising t.b./typhoid/HIV contacts
  • Pitfalls in Pediatrics(Surgery)
    • Not ruling out medical conditions before operating, e.g. Pneumonia/Effusion/ Hen Ö ch’s purpura in opening acute abdomen
    • Under/Over  appendicitis-all ages
    • Shying away from bone marrow or LN biopsies in Anemias; FUO; Nodes; Masses
    • Unnecessary surgeries-tongue tie; labial adhesions; meningocoeles with paralysed legs; umbilical hernia
    • Missing surgical causes-of chr. Diarrhoea; colics; constipation; bleeding pr; UTI; recurrent RTI/CNS inf.
    • Missing to examine genitalia- torsion/inf./hernias etc.
  • Pitfalls in Pediatrics(Psychology ):
    • Over labeling ‘functional’  Abnormal behavior/movements due to hepatic precoma, CNS tumors, chorea
    • Missing psy.causes for physical S/S
    • Failure to recognise child’s feelings
    • Failing to realise that there are more problem parents and homes than problem children- nail biting; bruxism; enuresis; encopresis
  • Pitfalls in Pediatrics(Psychology):Cont.
    • Failing to advise parents to set realistic and controllable goals
    • Giving medicines for IQ/Memory/ Mental
    • Retardation etc.
    • Believing that mild punishment/deprivation e.g. movies/tv are critical determinants in behavioral development
    • Failing to recognise variability of normal child behavior- 50%children lie or cheat on occasions
  • Pitfalls in Pediatrics-Neonatology :
    • Failing to obtain X-ray chest for RS distress; Abdomen for bilious vomiting; kull for cephalhematoma for #skull under it
    • Draining cephalhematoma
    • To neglect the most imp. Symptom- failure to suck (of any duration)-Sepsis/meningitis
    • Failing to note that sick neonate is usually afebrile or hypothermic
    • Faling to give vitamin K to all newborns
  • Pitfalls in Pediatrics-Neonatology:Continued
    • Failing to note significance of jaundice within 24 hrs and jaundice after or persisting > 14 days or recurrences
    • Failing to realise that CHD can be murmurless and vice a versa
    • Treating transitional diarrhoea or non-specific vomiting, when wt gain is ok
    • Not checking wt at each visit and head/ht
    • Postponing surgery of hernia
    • Failure to note that seizures can be very subtle
  • Pitfalls in Pedia.- Infant Feeding :
    • Not preparing for and insisting on breast feeding- it is both- art and science
    • To advise stopping BF for vomiting/ colics/ diarrhoea or for any illness or maternal Rx
    • To advise supplementary water or anything before 4 mo and not introducing weaning after 6 mo.
    • Milk intake > 1 Litre/day
    • Not checking Hb at 6-9-12 months
  • Pitfalls in Pediatrics-History & Exam.:
    • Assessing jaundice, cyanosis or skin rashes in fluorescent lamp light-call in daylight
    • Not reassessing or rechecking (re-evaluating)at rechecks-especially if symptoms are not improving or persisting
    • Believing in fevers when child is ok- not taking temp or charting if alleged f.u.o. and investigating and treating
  • Pitfalls in Pediatrics-R.S.
    • To miss h/o chest pain, tracheal shift
    • Importance of unilateral wheezing,  Air entry, dull note
    • Non-responding asthma-acidosis, infection, pneumothorax or dehydration
    • To label chr. S/s as TB or Asthma
    • Not considering eosinophilia, GER, f.b. etc
    • Shying away from chr. Cough as asthma
    • Shying away from inhalation steroid Rx
  • Pitfalls in Pediatrics:Cardiovascular Sy.
    • Most major CVS anomalies are murmurless
    • Harsher the murmur, minor the defect!
    • Relying too much on ECHO etc.
    • Failing to note Femoral pulses, cyanosis, BP, Signs of Bact. Endocarditis, CCF etc
    • Not giving prophylaxis for Rh. Chorea
    • Not looking for other anomalies!
  • Pitfalls in Pediatrics:GIT
    • To discontinue oral feeds, esp. Breast feeds in AGE/Chr.diarrhoeas/PEM
    • To consider simple Viral Hepatitis if jaundice is recurrent or prolonged> 6 weeks
    • To rely on skin turgor as a sign of dehydra.
    • To rely on fixed fluid calculations-it has to be assessed frequently-it’s a dynamic process
    • To use several drugs for diarrhoeas
    • Try to find cause of vomiting
    • To neglect or over-treat abdominal pain- acute, chronic or recurrent
  • Pitfalls in Pediatrics-GUT:
    • Not examining genitalia, B.P. & Urinary stream in dysuria, UTI etc.-we had a child 1yr with fever from neonataal period due to tight phimosis  bilateral hydronephrosis!
    • Treating AGN with steroids
    • Confusion bet. AGN, NS and UTI
    • Not withholding bakery products and fruits in AGN, HTN, ARF
    • AGN needs hospitalization
    • UTI in males-MUST investigate thoroughly. 60% have anomalies(surgical)
  • Pitfalls in Pediatrics-Vitamins-
    • Treating with repeated doses of massive vit. A and vit. D-they are toxic
    • Prescribing vitamin supplements for anything
    • Forgetting that vit. D is needed by growing child and not a marasmic one!
    • Not realising that Night blindness/xerosis/ keratomalacia are medical emergencies
    • Check tonics,contents and claims!
  • Pitfalls in Pediatrics:Neurology1
    • To diagnose simple Febrile seizures in a child <6months or > 5 years
    • To give AEDs for simple Febrile seizures
    • Labeling ‘mental deficiency’ on basis of single delayed milestone, or not checking prematurity or in 1 IQ/DQ assessment
    • To miss CNS infection just because neck stiffness or fever is not manifest
  • Pitfalls in Pediatrics:Neurology2
    • To miss characteristic vomiting of ICT-
    • projectile, no nausea, sudden, morning
    • Missing importance of sudden squint or head tilt, falls - it may be SOL in CNS
    • Guillain-Barre does occur in infants-children!
    • Not doing head measurement, auscultation, transillumination, fundoscopy
    • Plantars are extensor (  ) up to 2 years!
    • EEG can be normal in epilepsy and vice a versa- basis of AEDs is CLINICAL!
  • Pitfalls in Pediatrics-Endocrines
    • Failure to appreciate great variability of growth and sexual maturation-charting imp.
    • FTT < 5yr-nutritional/infections etc-non-endocrinal except hypothyroidism
    • Obesity is 99% non-endocrinal
    • IDDM: treating with OHA, low cal diet
    • Gynecomastia in 60% of normal boys
    • Use of thyroid hormone in Down’s, obesity, f.t.t., stunting, scholastic backwardness, fatigue
  • Pitfalls in Pediatrics:Infections
    • Not realising distinction bet. Infectious disease and Contagious disease
    • Not knowing period of infectivity
    • Missing Osteomyelitis in a case of Joint Pain and/or Swelling
    • PUO-Confirm its existence. Then UTI, TB., Deep abscess, Amoebic Hepatitis, HIV, Collagen disorders, Malignancy, Endocrine.
  • Pitfalls in Pediatrics:Infections-continued:
    • Forgetting that all fevers are not due to infections and –
    • Also forgetting that (serious) infections do exist without fever (esp. in infants & olds)
    • Over treating with antimicrobials(AMs)
    • Not using rational and logic in Ams
    • Dosage and Duration of Ams deserve more attention
    • Too much reliance on Culture-Sensitivity reports
  • Pitfalls in Pediatrics:Immunisations
    • To start vaccinating all over again if interval between consecutive doses lapse in time
    • Not maintaining proper position in freeze
    • Fomenting injection site!
    • Recommending against pulse polio
    • Insuring full protection from vaccine preventable diseases by vaccine doses
    • Forgetting to insist on follow up doses
  • Pitfalls in Pediatrics:Treatment1
    • Failing to note h/o Allergy on first page
    • Giving false credit of response to medication, which might occur even otherwise!
    • Too much Pharmaco-dependence- both patents and doctors
    • Treating symptoms only
    • Failing to treat symptoms
    • Anabolic steroids for height gain!-in fact they lead to stunting!(by early epiphiseal closure)
  • Pitfalls in Pediatrics:Treatment2
    • Inducing vomiting in Kerosene or Corrosive poisoning (recent case in DMH-2006)
    • Using empirical, unindicated, costly, dangerous, hypothetical or experimental drugs e.g. encephabol, placental extracts
    • Using anti-histaminics (AH) in asthma, collagen disorder
    • Use of topical AH-Caladryl must be banned! They are all potent sensitizers!
  • Pitfalls in Pediatrics:Pathology1
    • Over or Under use of laboratory
    • To treat investigations and not patient!
    • Believing that normal WBC count rules out lukemia
    • Attaching undue merit to Mantoux test
    • Under doing Bone marrow and CSF exams.
    • RA factor is –ve in >85% children of RA!
  • Pitfalls in Pediatrics:Pathology2
    • Wrongly interpreting pus cells in urine or stool reports
    • Wrong interpretation of ‘sugar’, ‘fat’. Undigested particles, cysts of E.histolytica
    • Culture report of commensals!
    • ALWAYS interpret in clinical context!
  • Pitfalls in Pediatric Orthopedics
    • Forgetting that most fractures heal with minimum treatment
    • Infections of bones and joints are common
    • There can be referred pain-esp. knee  hip
    • Tumors are common-and highly malignant
    • Metabolic diseases are common. So also storage disorders
    • Absent bones can be imp. Clues to hematologic conditions
    • Neglecting leg pains, limps etc.(Perthe’s, spine anomalies etc.)
  • Pitfalls in Pediatrics:Dentistry
    • Unscientific approach->Caried tooth need not be treated- they will fall off!
    • Missing dental infections as a source of chronic ill health, Bact.endocarditis etc.
    • Giving vit.D for delayed eruption, caries
    • Not advising preventive fluoride pasing every 6 months
    • Malocclusion needs orthodontic treatment
  • Pitfalls in Pediatrics:Ophthalmology
    • Not looking for Cataracts, Squints
    • Delaying needling NL duct blocks
    • Using Steroid combinations for conjunctivitis and other infections
    • Medical indications for contact lenses if myopia > -3; kerartotomy>21yrs only
    • Eye is an extension of CNS!It is mirror of many systemic disorders too!