Here is a summary of the treatment plan for the index case:
- Admit the patient and start IV antibiotics like ampicillin and gentamicin to treat pneumonia. Also give nebulization with asthalin.
- Provide supportive care including IV fluids, oxygen supplementation if needed, antipyretics and physiotherapy.
- Once pneumonia is treated and symptoms improve, continue oral antibiotics like cotrimoxazole for a total of 10-14 days.
- Monitor the patient closely and watch for any deterioration which may require changing antibiotics.
- Follow guidelines for routine health supervision in Down syndrome including screening for cardiac, vision, hearing and other issues.
Apnea (AP-nee-ah) is a pause in breathing that lasts 20 seconds or longer for full-term infants. If a pause in breathing lasts less than 20 seconds and makes your baby's heart beat more slowly (bradycardia) or if he turns pale or bluish (cyanotic), it can also be called apnea.
A group of Pediatricians from Chandigarh discussing common OPD problems in office practice.
5 minutes per topic for the speaker ONLY, discussing 15-20 topics every time !
3. Personal Data
• Patient name- Shreya
• Age- 1 year 4 months
• Date of birth- 29/03/2011
• Address- Bantwala
• Informant- Mother – 7th std (reliable)
• Date of admission- 2/8/2012
5. History of presenting illness
• Cough – associated with expectoration
Onset- insiduous
Gradually progressive
Present throughout the day
No aggravating factors
Relieved on medication
7. • Breathlessness
Associated with cough and expectoration
Associated with occasional wheeze
Worsens on lying down, at night
Relieved when mother holds baby upright
8. • Came to GWH on 30th July with above
complaints
• Nebulization done
• Symptoms subsided
• Patient discharged the same day
• Symptoms recurred 3 days later,
admitted.
9. Past history
• Has had similar episodes in the past
since the age of 1.5months
• 3 admissions
• Nebulization done each time
10. Antenatal history
• Age at first pregnancy: 26 years
• Birth order-5
• h/o 3 abortions – 4th, 5th and 6th month of
gestation
• Age at 4th pregnancy: 29 years (baby
healthy)
• Age at 5th pregnancy : 31 years
11. • Spontaneous conception
• 1st trimester- No history of fever with rash,
exposure to drugs or radiation, increased
frequency or burning micturition. IFA
tablets taken.
• 2nd trimester- No history suggestive of PIH/
GDM. T.T injections taken
• 3rd trimester- No history suggestive of
PIH/GDM
• 4 USG done. Anomaly detected at 8th
month POG (Down’s syndrome)
12. Natal and postnatal history
LSCS at 9th month
Cried immediately after birth
Birth weight – 2.8kg
Breast feeding initiated after 2 hrs
NICU admission- 4days – phototherapy
Passed urine and meconium
13. At 1.5 months age:
• Diagnosed to have Down’s syndrome
• Child being taken for physiotherapy twice
a week since the age of 1.5 months
• h/o recurrent respiratory infections
• No h/o constipation / vomiting/ bleeding
gums or from other sites
• No h/o impaired vision or hearing
• No h/o nasal regurgitation of food/choking
14. • h/o feeding difficulty since 1.5 months
of age
• Inability to feed continuously
• h/o inadequate weight gain
• No history of orthopnoea, cyanosis,
syncope or edema
15. Developmental history
• Social smile - 8 months
• Recognized mother- 9 months
• Stranger anxiety – 1 year
• Head control – 1 year
• Rolling over – 1 year
• Unidextrous grasp – 1 year
• Monosyllables- 14 months
• Bisyllables- 16 months
17. Diet history
• Exclusively breast fed till 6 months of
age
Calories(kcal) Proteins(g)
Breakfast 226 6.4
Lunch 302 7.7
Snacks 290 4.1
Dinner 88 1. 7
Total 791+ 402= 1190 18.5+6.6=25
Expected 1030 22
18. Family history
• Total family members- 4
• Non consanguineous marriage
• Parents healthy.
• No history of TB/ congenital defects/
allergy in the family
19.
20. Summary
• 16 months old baby , a known case of
Down’s syndrome, came to RAPCC with
cough and expectoration and
breathlessness 6 days prior to admission.
Patient has history of recurrent respiratory
tract infections, feeding difficulty since 1.5
months , was diagnosed to have a cardiac
anomaly at 1.5months of age.She has
global developmental delay. She is
immunized up to date and no calorie
deficit
22. VITALS
• Pulse rate-104 beats per min (normal)
• Respiratory rate-36 per min
(tachypnea)
• Afebrile during examination
23. ANTHROPOMETRY
• Weight for age
• Less than 3rd percentile
• Grade 1 PEM (IAP)
• undernutrition (wellcome trust)
24. • Length
• Less than 3rd percentile
• Grade III stunting (waterlow
classification)
• Weight for height
• No wasting (waterlow classification)
25. • Head circumference
• Microcephaly (less than 3rd percentile)
• Brachycephaly is present
• Mid arm circumference-14
cm(normal)
• Chest circumference is greater than
head circumference
26. Head to toe examination
• Sparse thin shiny hair
• Flat occiput
• Ant fontanelle-1*1cm
• Depressed nasal bridge
• Hypertelorism
• Epicanthic fold present
27. • Up-slanting of eyes
• Low set ears
• Mouth kept open with protruding
tongue
• Short neck
• Short broad hands
• Hypotonia,hyperflexible limbs
• Kennedy crease
30. RESPIRATORY SYSTEM
• Respiratory rate-36/min
• On Inspection,abdominothoracic
respiration,movements bilaterally
symmetrical
• On Palpation,trachea is central,inspectory
findings confirmed
• On percussion,resonant note heard in all
areas
• On auscultation,breath sounds of equal
intensity bilaterally,vesicular,crepitations
heard bilaterally
31. • Cardiovascular system
• S1 S2 heard,no murmurs
• CNS
• Hypotonia,power cannot be
assessed,reflexes are normal
• P/A
• Soft nontender,no organomegaly
41. INVESTIGATIONS FOR DOWN S
SYNDROME
• Karyotyping.
• To diagnose complications-
• Complete blood count.
• Peripheral smear
• Radiological findings
• X ray spine
• X ray chest.
• X ray bones.
• X ray pelvis.
42. • AUDIOLOGY
• OPHTHALMOLOGICAL.
• THYOID FUNCTION TESTS.
• ECHO-PDA with Left to Right shunt.
• BLOOD SUGAR.
46. BIOCHEMICAL INVESTIGATIONS
• ELECTROLYTES
Na+,K+,Cl-,HCO3
‘LIVER FUNCTION’ TESTS
Total and Direct Bilirubin ; ALT
• ARTERIAL BLOOD GAS ANALYSIS
• THYOID FUNCTION TESTS.
53. PNeuMONIA
• INdICAtIONs fOr hOsPItAlIsAtION :
• At tIMe Of dIAgNOsIs:
Features of hypoxia ( restlessness, anxiety, cyanosis. Inability
to sleep, talk, walk, unconsciousness, seizures) ; Reduced
urine output/ dehydrated ; Vomiting/ poor oral intake
High risk factors
• durINg treAtMeNt
No improvement/ progressive deterioration when on treatment
as outpatient
54. OutPAtIeNt MANAgeMeNt
• 1 – 5 years age :
• Paediatric Tablet Cotrimoxazole (Sulphamethoxazole 100 mg
and trimethoprim 20 mg ) - 3 tablets twice a day
• Reassess after 48 hours
• If improves – continue for 3 more days. No improvement –
continue for 48 hours and reassess.
• Explain parents WARNING SIGNS – return immediately
55. INPAtIeNt MANAgeMeNt
Specific Supportive
Antibiotics Hydration
Nutrition
Oxygen
Antipyretics
Physiotherapy
Asthalin nebulisation if wheeze is
present
56. ANtIbIOtICs
• Benzyl penicillin/ ampicillin / 3rd generation cephalosporin +/-
aminoglycosides
• Inj. Benzyl penicillin – 5000IU per kg/dose 6th hourly IM
• Inj. Ampicillin – 50mg/kg/dose 6th hourly IM
• Inj. Gentamicin – 2.5 mg/kg/dose 8th hourly IV
• Continue for 10-14 days
• Assess twice a day – if deterioration :
CXR to look for staphylococcal infection
(pneumatoceles ) – change to cloxacillin
• Atypical pneumonia - macrolides
57. suPPOrtIVe CAre
• Fever – Paracetamol (10-15 kg/dose ) every 4 to 6 hourly
• Tachypnea, cyanosis, chest indrawing – oxygen by oxygen
hood, oxygen mask, nasal catheter, nasopharyngeal catheter
• Not drinking/dehydrated – IV fluids
• Asthalin nebulisation : if wheeze present
58. treAtMeNt Of the INdex CAse
• Nebulisation with asthalin
• IV fluids Iso – P
• Inj. Ampicillin IV
• Injection Gentamycin IV
• Syp PCT
60. dOWN sYNdrOMe – heAlth
suPerVIsION
Condition Time to screen Comment
Congenital heart Birth 50% risk for congenital
disease Young adult for heart disease.
acquired valve disease Increased risk for
pulmonary
hypertension
Strabismus, cataracts, Birth or by 6 months 15% - cataracts
nystagmus Check vision annually 50% - refractory errors
Hearing impairment or Birth or by 3 months – Congenital hearing loss
loss ABER 70% risk – serious
If tympanic membrane otitis media
not visualised- 6
monthly for 3 years
Annually therafter
Constipation Birth Hirschsprung disease
61. dOWN sYNdrOMe – heAlth
suPerVIsION
Condition Time to screen Comment
Celiac disease 2 years/ symptomatic Screen – IgA and
tissue transglutamase
antibodies
Hematologic disease At birth , adoloscence Neonatal polycythemia
and when symptoms Leukemoid reaction
develop Leukemia
Hypothyroidism Birth, repeat at 6 – 12 1% - congenital
months and then 5% acquired
annually
Growth and At each visit Discuss school
development Use Down syndrome placement options
growth curves Proper diet to avoid
obesity
64. dOWN sYNdrOMe – heAlth
suPerVIsION
Condition Time to screen Comment
Obstructive sleep apnea Start at 1 year. Then at Monitor for snoring,
each visit restless sleep
Atlantoaxial subluxation/ Each visit – history and Maybe asymptomatic
instability physical exam
Radiographs at 3 -5
years or when planning to
participate in contact
sports / Transient
neurological symptoms
Gynaecological care Adoloscent girls Menstruation/
contraception use
Recurrent infections When present Check IgG subclass and
IgA levels
Psychiatric, behavioral Each visit Depression,anxiety,
disorders OCD, schizoprenia.
Autism , Early onset
alzheimers
65. PdA - left tO rIght shuNt
• Catheter based treatment – occlusive devices or coils
• Surgery if :
• Large PDA ( larger than size of available devices)