This document provides guidance on common pitfalls in pediatric practice. It discusses accurate assessment of newborns, including gestational age and causes of jaundice. Common issues are outlined for post-neonatal periods up to age 3, including causes of vomiting, cardiac murmurs, growth monitoring, and dehydration assessment. Guidance is provided on intussusception, pulmonary conditions, urinary tract infections, and neurological signs. Specific conditions like Kawasaki disease are also summarized. The document emphasizes considering diverse potential causes and having a high index of suspicion to correctly diagnose common pediatric problems.

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Dehydration difficult to assess in obese & malnourished children - assess pulse rate - assess weight SHOCK IN CHILDREN IS ALWAYS DUE TO DEHYDRATION UNLESS PROVED OTHERWISE.

10. 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

11. Pulled Elbow 6 months – 2 yrs Three months Colic. Viral Group – Typical History Epiglotitis – Red Epiglottis Torsion Testis Obstructed Hernia Diaper Dermatis

12. 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

13. 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.

14. 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

15. 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.

16. 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

17. 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.

18. 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.

19. Todd's Paralysis * Lateralisation after GTC * Hypo / Hypertonia Areflexia / Hyperreflexia Lasts for upto 7 days Recovers on its own. No investigations or treatment required.

20. 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

21. Thank You