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Pitfalls in pediatrics


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Pitfalls in pediatrics

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