Common questions in OPD practice in Pediatrics - 15 questions in 1.5 hours by 5 experts - Aug 2018, Chandigarh. Unique format - Extensive Learning

1. Dr. Ridhi, Dr. Shailesh, Dr. Sunny, Dr. Gaurav, Dr. Sandip
31st Aug, 2018

2. 1. Role of Monteleukast in
Pediatric Asthma
 Dr. Shailesh

3. DR SHAILESH MEHTA

4. MONTELEUKAST IN ASTHMA
MONOTHERAPY VS ADD ON WITH ICS VS ADD ON WITH
SABA AND LABA
 COCHRANE SAYS NO SIGNIFICANCE
Cochrane Database Syst. Rev.2, CD005602 (2006).
Cochrane Database Syst. Rev.5, CD003137 (2011)
 META ANALYSIS SAYS NO SIGNIFICANCE-
Eur J Pediatr (2017) 176:963–969
 MOST INDIVIDUAL STUDIES PROMISING
Bérubé et al. Allergy, Asthma & Clinical Immunology
2014, 10:21
 PHYSICIAN AND PATIENT SATISFACTION
ENCOURAGING

5. 2. Macrolides in LRTI & Wheezing
children - EBM
 Dr. Sandip

6. LITTLE OVERLAP WITH CAP

7. Suspect atypical pneumonia
 persistent low-grade fever.
 cold or flu-like symptoms that persist longer than 7-10
days.
 a persistent dry cough.
 wheezing while breathing.
 they have fatigue or don't feel well and it doesn't get
better.
 chest or stomach pain.
 vomiting.

8. Mycoplasma Pneumonia/walking
pneumonia
 The symptoms are much worse than physical signs
 Chest Exam may reveal crepts, localized wheeze
and small areas of dullness to percussion over
atelectatic areas or fluid collection.
 Radiographic changes in mycoplasma pneumonia
are not specific and may include
 broncho-pneumonic infiltrates, generally in one of the
lower lobes.
 Small areas of segmental or sub-segmental atelectasis
are also common.

9. CAP: likely pathogens
 One-third of cases of CAP (8-40%) represent a mixed infection.
 Mycoplasma is not unusual in children aged 1-5 years
 Infection peaks between 6 to 12 yrs(20 to 25% )
 Viruses alone are found as a cause in younger children in up to
50%.
 In older children, when a bacterial cause is found, it is most
commonly - S pneumoniae followed by mycoplasma and
chlamydial pneumonia.
 Chest physiotherapy has no role in uncomplicated CAP
 Macrolides are drug of choice for atypical infections.
 Azithromycin is DoC. Clarithromycin is alternative.

10. 3. Grey & White hair in Children?
 Dr. Ridhi

12. Etiology
 Hereditary: AD trait
 Autoimmune disorders: pernicious
anaemia, hyper or hypothyroidism.
 Atopic diathesis
 Nutritional causes: deficiency of proteins,
iron, folic acid, vitamin B12, copper, calcium,
vit D, malabsorption syndromes, nephrosis,
kwashiorkor
 Environmental damage: pollution, UV rays
from sun, harsh chemicals, smoking

13. Investigations
 CBC
 Thyroid profile
 Vitamin B 12 levels
 Serum Ferritin
 Vit D

14. Treatment
Find the cause
 nutritional deficiency- supplements.
 If the thyroid hormonal profile is deranged, look for
autoimmune diseases
 calcium pentathionate might help premature greying of
hair independently. Tab Kerablak 100-300 mg/day.
 Topicals:
 Melitane (a MSH antagonist ) stimulates melanin
production
 Q Sera black: anti sun and anti ageing hair serum

15. Home Remedies
 Amla
 Coconut oil and curry leaves
 Tea
 Coffee
 Coconut milk
 Henna
 Curd

16. 4. Pediatric Asthma Guidelines -
Step UP & DOWN - Practical tips
 Dr. Sunny

17. Asthma approach, practical aspects
Common scenarios
1)Intermittent: viral induced
exercise induced
intermittent multi trigger
2)Persistent :well controlled or poorly controlled
3)exacerbation

18. Divide age
 2-5 years
 More than 5 years

19. See control/ classify if first visit
Practically we can divide it into
 Good control
1) Less than 2 times rescue therapy per week
2) Less than 2 day time symptoms per week
3) Less than 2 exacerbations per year
4) PEFR more than 80 percent

20. Poor control
2 or more rescue per week
2 ormore more day symptoms per week
2 or more exacerbations per year
PEFR less than 80 percent
PEFR less than 60 percent , treat as exacerbation

21. Less than 5 years steps
 Low dose inhaled steroids plus asthalin/levolin
 Consider adding monteleukast
 Increase to medium dose inhaled steroids
 Increase to high dose inhaled steroids
 Last to try oral steroids

22. More than 5 years
 Low dose inhaled steroids / asthalin or levolin
 Increase to medium dose
 Add long acting , salmetrol or formetrol
 Try monteleukast ( not very concrete role)
 Shift to high dose inhaled steroids plus LABA

23. Exercise induced and viral induced
 Try managing with levolin and asthalin if episodes are
mild or infrequent (3 or less per year)
 if any severe episode, treat it as asthma
 Frequent episodes , treat it as asthma
 In some patients monteleukast may work little better
as preventive therapy

24. Budesonide
2 – 5 years
 Low dose mod dose high dose
100 200 400
5 – 12 years
200 400 800

25. When to change med
 Step up every one month to 3 months if no response
 Step down after 3 months if well controlled
 STEP DOWN approach in acute exacerbation
THANKS

26. 5. HRIG V/s Monoclonal ABs in
Rabies prophylaxis
 Dr. Gaurav

27. Short comings of ERIG/HRIG
27
Potential risk of
blood borne
pathogens
High cost
(HRIG)
Limited
availability
High risk for
severe allergic
reactions (ERIG)
Batch to batch
variation
Human/ Animal
donors needed

28. Monoclonal Antibody
 Unlike Polyvalent antibodies in ERIG/HRIG which binds to
different antigens, monovalent affinity for targeted
molecule/antigen
 Binds to same epitope or part of antigen or virus
 Advantages:
 High Purity
 Highly potent
 Offers reproducible & reliable results
 Excellent batch-to-batch consistency
 Capable of being produced in high quantities
28

29. Superiority of Rabishield
over HRIG & ERIG
 Technology: Developed using recombinant technology unlike RIG
 Highly potent: Dose 3.33 IU/Kg body weight, Lower volume reqd
(6.25 ml Vs. 10 ml for 75 Kg person, easier infiltration)
 Sensitivity: No skin sensitivity test unlike ERIG
 Efficacy: Proven to neutralize all rabies isolates found in India
 Availability: Quick Upscaleable, guarantees unlimited availability
 Economical: Great cost benefit compared to HRIG
29

30. 30
Parameter Rabishield HRIG
MRP per vial Rs 1970 Rs 5286.48
30 kg child 30 x 3.33 IU
= 100 IU
30 X 20 IU
= 600 IU
No of Vials -
MRP cost
1
Rs 1,970
2
Rs 10,573
60 kg adult 60 x 3.33 IU
= 199.8 IU
60 X 20 IU
= 1200 IU
No of Vials -
MRP cost
2
Rs 3,940
4
Rs 21,146
75 Kg adult 75 X 3.33 IU
= 249.75 IU
75 X 20 IU
= 1500 IU
No of Vials -
MRP cost
3
Rs 5,910
5
Rs 26,432
Comparative Cost analysis vs HRIG

31. WHO position paper 2018
 mAb is safe and effective in clinical trials
 Has comparative advantages incl
 large scale production with standardized quality,
 greater effectiveness than RIG,
 elimination of the use of animals,
 and reduced adverse effects.
 If available, use of mAb products instead of RIG is
encouraged

33. 6. Deworming - is it really needed?
 Dr. Shailesh

34. DR SHAILESH MEHTA
M.D. PEDIATRICS

35. A. Lumbricoides T. Trichiura Hookworm
IF PREVALENCE MORE THAN 50% ,
REGULAR ANNUAL DEWORMING IS INDICATED - WHO 2006
INDIAN DATA-BMC Public Health (2017) 17:201

36. DOSES SCHEDULES OF DEWORMING- CDC 2016
 Ascaris And Hookworm
Albendazole 400mg Single Dose
Mebendazole 100 Mg Twice A Day -3 Days
 Trichuris Is Treacherous –
Needs 3-7 Days Doses Of Albenda /Mebenda
 Enterobius Vermicularis
Albendazole 400mg Single Dose
Repeat 400 Mg After 14 Days
Mebendazole 100mg Single Dose
Repeat Mebendazole 100 Mg After 14 Days

37. 7. Recurrent Vulvovaginitis
 Dr. Sandip

38. Recurrent vulvovaginitis
 Vulvovaginitis is generally considered to be the
commonest gynaecological problem in prepubertal
girls,although the incidence is unknown.
 In practice, the terms vulvitis, vaginitis, and
vulvovaginitis are often used interchangeably by
doctors in diagnosing inflammatory conditions of the
lower female genital tract.
 Thrush is most unlikely reason for above and the most
common prescription given.

39.  Symptoms
 Vaginal discharge (62-92%)
 Redness (82%)
 Soreness (74%)
 Itching (45-58%)
 Dysuria (19%)
 Bleeding (5-10%)
 Physical signs
 Inflammation (redness of the introitus in 87%)
 Excoriation of the genital area
 Vaginal discharge

40. Causes of vulvogainitis
 Irritants
 Infections
 Threadworm
 Poor hygiene
 Sexual abuse
 Thrush
 Foreign body
 Eczema lichen planus
 Rare causes like tumours

41. Increased genital
erythema can be
caused by local
irritants, infection, or
rubbing of tissues.
This child had
nonspecific
vulvovaginitis caused
by sensitivity to
bubble baths.

42. Labial adhesions
can be extensive or
minimal. This child
was having
difficulty urinating
because of almost
complete adhesion
of her labia and
needed treatment
with topical
estrogen cream for
4 weeks

43. patient was
examined for
possible sexual
abuse because of
constant complaints
of pain and itching
in genital area.

44. This 8-year-old girl
complained of genital
itching and had spots of
blood on her underpants.
Pattern of
hypopigmentation, with
clear demarcation of
normal and affected skin,
is typical of lichen
sclerosus. Atrophic skin
bleeds easily, even with
gentle wiping with tissue.

45. Foreign bodies are not unusual in young girls. Most
common foreign body is piece of toilet tissue that
child inserts herself. Photo shows white piece of
tissue, which can usually be removed by gentle
irrigation with warm water.

46. Photo shows injuries to 9-
year-old girl who was raped.
She has tear through hymen,
posterior fourchette, and
vagina, with bruising of
tissues as well.

47. Advice to parents
 Clothing and laundry
 Hygiene
 Physical activities
 Avoid activities that put direct pressure on the vulva (e.g. bicycle riding
or horse riding).
 Remove sports clothing soon after exercise.
 Place a frozen gel pack wrapped in a towel against the itchy area to
relieve symptoms after exercise.
 Have a break from swimming in chlorinated pools and avoid hot tubs
 Avoid long periods of sitting – encourage regular breaks of standing or
walking.
Relieving itch
 Encourage your child to not scratch the area.
 Soak a clean, soft cloth in a bowl with cool water and your soap
substitute, and apply to the vulval area to help relieve the itch.

48.  Bacterial vaginitis: suspect in children with thick mucoid
discharge,fever,lower abdominal pain and dysuria
 Sexual abuse: always keep in mind while examining such
children
 NAAT test is gold standard in diagnosing Gonorrhoea and
Chlamydia infections
 Never treat swab culture with mixed organisms. However
single isolation of a bacteria along with prominent
symptoms needs treatment .
 Common offenders: gut coliforms, groupA streptococci,H
influenzae
 Take swab if symptoms are prominent ,recurrent or
persistent

49. 8. Vit A supplementation - should it
be done in PP, and how?
 Dr. Ridhi

51. Is it required in private practice?
 8 state surveys in 2003 suggest that 62% of
preschoolers in India are vitamin A deficient (s. retinol
<20 μg/dL
 In urban central India (Nagpur), the mean prevalence
of xerophthalmia is about 6.5% based on Bitot spots
and/or night blindness (2011 study)

52. Points to note
 Deficiency is now limited to isolated geographical
pockets in the country.
 no evidence of benefit of VA supplementation of
children without clinical signs of deficiency.
 Vitamin A is toxic in high doses. The mega-dose of
vitamin A (200, 000 IU) given to children is 500 times
higher than the daily recommended dose (400 IU).

53. Possible adverse effects
 Bulging fontanel: Nearly 12 per cent of young
children when administered 50,000 IU of VA
developed bulging fontanel
 Vitamin D antagonism: bone demineralisation
 Potential zinc deficiency
 Risk of acute respiratory infection
Focus efforts on sustainable food based approaches
to combat vitamin A deficiency

54. 9. Recurrent Leg Pain - Diagnosis &
Treatment
 Dr. Sunny

55. LEG PAIN
 Common in 3 to 5 yrs or 8 to 12 yrs
 Evening and night
 We call it growing pains
 Run in families

56. Purple Flag signs
 Pain in one leg or arm or back
 Pain all day
 Pain in joints
 Fatigue and lethargy
 Limping or difficulity in walking
 Presence of systemic signs

57. Flag signs on examination
 Bruises
 Joint swelling
 Weakness in muscle power
 Tenderness localised or generalised
 Swelling/ any sign of inflamation
 See femoral pulses
 See for lump anywhere along bone or muscle

58. Basic investigations
 X ray
 vit D
 CBC
 ONLY TO BE DONE IN SELECTIVE CASES

59. GROWING PAINS
 Have no relation to growth !!!!
 THANKS

60. 10. The HOLD - how to calm a crying
baby in OPD & impress the parents !
 Dr. Gaurav

62. 11. Clobazam (Frisium) in Febrile
Seizure Prophylaxis -
recommended? Any alternatives ?
 Dr. Shailesh

63. DR SHAILESH MEHTA

64. EVIDENCE BASED FACTS
 Cochrane meta- analysis and ILAE don’t support
use of CLOBAZAM in febrile seizures.
Cochrane Database of Systematic Reviews 2017, Issue
2. Art. No.: CD003031.
included 40 articles describing 30 randomised trials
with 4256 randomised participants
RESULT: CLOBAZAM INEFFECTIVE
 Most studies in favour have sample size 25-70
patients only
Indian J Pediatr (2011) 78:38–40
Manreza et al,Arq Neuropsiquiatr 1997;55(4)
Rose et al, Indian J Pediatr 2005;72(1)

65. RESCUE VS PROPHYLAXIS
Rescue- If Seizure More Than 15 Min
Diazepam I.V./ Rectal-0.3- 0.5mg /Kg/Dose
Midazolam Intranasal-0.2mg/Kg/Dose
Clobazam- Not Used
Cochrane Database Of Systematic Reviews 2017, Issue
2. Art. No.: Cd003031
Lancet 2005,;366:205-10
Prophylaxis-
No More Used- Phenobarb, Valparin
Diazepam(oral) – 0.3 Mg/Kg/Dose 8 Hourly
Till Afebrile For 24 Hrs
Clobazam(oral)- 0.5 Mg/Kg/Dose- 12hourly- For 48hrs
Range 0.3-1mg/Kg/Dose

66. 12. Effective counseling for Obese
Kids in a Busy OPD practice
 Dr. Sandip

67. Obesity counseling
 First point to make out is obesity is not a cosmetic but
a medical problem
 Parents do not understand BMI or Z scores
 However showing them the discrepancy in weight and
growth percentiles give a better visual impact
 Acanthosis nigricans and enlarge liver if present can
alert them to the coming problems
 Talk about metabolic syndrome in such cases.

68.  Make exercise and healthy eating a family affair rather then
singling out the index child.
 Cut down all empty calories, Cut down junk
 Stop unhealthy snacking
 Don’t skip breakfast
 Engage them in activity which make them sweat. Dance is
fabulous.
 Most kids may not drop weight but will outgrow with
increasing height.
 Stop eating in front of TV ,Limit use of gadgets
 Don’t allow kids to eat in isolation. Encourage family meals
 Stop cooking separate meal for kids
 Don’t expect overnight results, Do not give medications
from TV adverts

69. 13. Infant with Cradle Cap - what is
safe & effective?
 Dr. Ridhi

71. Etiology
Overactive sebaceous glands(maternal hormones)
Excess oil production
Dead skin cells get caught in the oil
Clump formation

72.  Role of Malassezia (yeast)
colonizes baby skin
Redness and inflammation
Build up of sebum and dead skin cells
 Role of Fungus

73. Remedial measures
 Bathe your baby once a day.
 Use a gentle shampoo 2-3 times a week.
 Vitamin B supplements to nursing mother.
 Brush baby’s scalp with a soft brush.
 Apply baby oil before brushing.
 Be patient.
 Mild steroids if inflammed
 Ketoconazole shampoos better avoided

74. 14. Recurrent Mouth Ulcers - Invx
& Treatment options
 Dr. Sunny

75. ULCERS IN MOUTH
 1) onset : acute or chronic
Acute : infective , traumatic , allergy
Chronic : igA def, neutropenias , HIV, allergy ,
Malabsorbtion like celiac and chrohns
 2 )single or multiple
multiple are usually infective mostly viral

76.  Recurrence
Rule out systemic illnesses , allergy , celiac, chrohns,
think of neutritional deficiency
 Location
Traumatic may be on buccal mucosa or lateral part of
tongue

77. Recurrent aphthous ulcers
 No casual relationship to anything
 Family history may be positive
 Look for anaemia : iron and B12 def implicated in some
pts
 B 3 or vit C def in some studies but usually no
relationship
 Vit D def (poor evidence)….. King of all diseases !!!!

78. What to do
 Probably nothing
 May give a trial of vit B or C
 Usually get ok in thirties

79. 15. Doctor Pharma interaction.
What the MCI guidelines say?
 Dr. Gaurav

80. https://www.mciindia.org/documents/rulesAndRegulations/Ethics%20Regulations-
2002.pdf

83. https://www.mciindia.org/documents/rulesAndRegulations/Ethics%20Regulations-
2002.pdf

85. RIP
Mohani Kanungo
(1967 – 2018)