1. Failing to keep up with changing medical knowledge and concepts, relying too heavily on tests and reports, and not thoroughly examining patients can lead to missed diagnoses or improper treatment. 2. It is important to consider common conditions first, get additional opinions if the patient is not improving, and refer to specialists in a timely manner when needed. 3. Pediatricians must thoroughly assess patients' medical histories and symptoms, as underestimating any complaint can be a pitfall.

1. PITFALLS IN PEDIATRICS DR JAYANT NAVARANGE M.D.,D.C.H.,LL . B. HON. PEDIATRICIAN-> P.H.R.C.; DEENANATH & SAHYADRI HOSPITALS; SHREEVATSA; BSSK ORPHANAGES Chairman, Medico-legal Cell, IMA,Maharashtra State, & Pune Br and I AP, Maharashtra

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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!

16. 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

17. 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)

18. 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!

19. 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

20. 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!

21. 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

22. 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.

23. 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

24. 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

25. 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)

26. 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!

27. 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!

28. 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!

29. 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.)

30. 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

31. 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!

32. THANK YOU