What nelson forgot 4 - Super CME for Common Pediatric OPD questions, 12th July 2019 Common Office practice questions, answered in just 5-10 minutes per topic ...

1. What Nelson Forgot - 4
Super CME, 12th July 2019
STARRING (in alphabetical order :)
Dr. Amit, Gaurav, Manoj, Ridhi, Roosy, Sandeep & Shailesh

2. Topics for discussion
1. Melatonin - Role in children including sleep disorders - Dr. Roosy
2. First episode of afebrile seizure - how to manage - Dr. Roosy
3. Green nasal discharge - Is it important - Dr. Sandeep
4. Tips for examining a child – Dr. Sandeep
5. Acne – What a Pediatrician needs to know – Dr. Ridhi
6. Fever with Loose motions – when to use Antibiotics – Dr. Ridhi
7. Mosquito repellants in children –Dr. Shailesh
8. Should we use anti-malarials empirically for fever? – Dr. Shailesh
9. Mesentric adenitis - Dr. Amit,
10. Urine analysis - collection & interpretation - Dr Amit
11. Atopic March, can it be stopped? – Dr. Manoj
12. Three simple devices that may change your OPD practice – Dr Gaurav

3. Melatonin in Pediatrics:
Therapeutics
Dr. Roosy Aulakh
Associate Professor
GMCH 32 Chandigarh

4. MELATONIN SECRETION

5. MELATONIN AVAILABILITY

6. MELATONIN PROPERTIES
Chronobiotic
Anxiolytic
Sedative
Anaesthetic
Anti-oxidant
Anti-epileptic

7. Melatonin Uses………..Case Studies
Dyssomnias: Non 24HSWD
Neurological Disorders
• Autism Spectrum Disorders (ASDs)
• Attention-Deficit Hyperactivity Disorder (ADHD)
Pediatric Anesthesia & Sedation
Epilepsy and Febrile Seizures
Adolescent Idiopathic Scoliosis (AIS)
Neonatal Care
• Sepsis, asphyxia, respiratory distress, or surgical stress

8. Melatonin Uses………..Case Studies
Dyssomnias: Non 24HSWD
Neurological Disorders
• Autism Spectrum Disorders (ASDs)
• Attention-Deficit Hyperactivity Disorder (ADHD)
Pediatric Anesthesia
Epilepsy and Febrile Seizures
Adolescent Idiopathic Scoliosis (AIS)
Neonatal Care
• Sepsis, asphyxia, respiratory distress, or surgical stress

9. Melatonin Uses………..Case Studies
Dyssomnias: Non 24HSWD
Neurological Disorders
• Autism Spectrum Disorders (ASDs)
• Attention-Deficit Hyperactivity Disorder (ADHD)
Pediatric Anesthesia & Sedation
Epilepsy and Febrile Seizures
Adolescent Idiopathic Scoliosis (AIS)
Neonatal Care
• Sepsis, asphyxia, respiratory distress, or surgical stress

10. Melatonin Uses………..Case Studies
Dyssomnias: Non 24HSWD
Neurological Disorders
• Autism Spectrum Disorders (ASDs)
• Attention-Deficit Hyperactivity Disorder (ADHD)
Pediatric Anesthesia & Sedation
Epilepsy and Febrile Seizures
Adolescent Idiopathic Scoliosis (AIS)
Neonatal Care
• Sepsis, asphyxia, respiratory distress, or surgical stress

11. Melatonin Uses………..Case Studies
Dyssomnias: Non 24HSWD
Neurological Disorders
• Autism Spectrum Disorders (ASDs)
• Attention-Deficit Hyperactivity Disorder (ADHD)
Pediatric Anesthesia & Sedation
Neonatal Care
• Sepsis, asphyxia, respiratory distress, or surgical stress
Neonatal Feeding

12. Acne- What a pediatrician
needs to know
Dr. Ridhi

13. • Age of onset: F 12-14 yrs, M 14-16 yrs, occ 7-8 yrs
• Neonatal acne (20%), infantile acne (1-3 yrs)
• Diet: high glycemic index-> insulin and IGF-
>androgens
• Premenstrual flare: 25-50%
• Sweating, stress, smoking, winters
• Repetitive cleansing harmful as it irritates the skin

15. • GRADING:
• 1-comedones, papules and pustules<10
• 2-papules and pustules 10-40
• 3-papules and pustules 40-100, nodules<5
• 4-nodulocystic acne and acne conglobata
• TRETMENT:
• Patient education: mild acne persists 4-6 yrs and
severe >12 yrs
• 20% improvement after 2 months therapy and 80% @
8 months

16. • Inflamed lesions:
Topical benzoyl peroxide-2.5-5% conc, no resistance- PERSOL or
Topical antibiotics- Clindamycin, Erythromycin- resistance or
Azelaic acid-20% -antimicrobial, keratolytic – AZIDERM
PLUS
Topical Retinoids-Retinoic acid (.01-.05%)-@ night,local irritation or
Adapalene (less irritation)-ADAFERIN(.1%) or
Tazarotene-TAZRET
• Noninflamed lesions:Topical retinoids
• ORAL MEDICATIONS: moderate-severe acne, depression, prone to scarring
or pigmentation
Antibiotics-Tetracycline, Doxycycline, Azithromycin, Erythromycin
Isotretinoin-.5-1 mg/kg/day for 16-20 weeks,teratogenic ISOTROIN 10/20
Steroids, OCPs, Zinc

17. URINE ANALYSIS
collection & interpretation
Focus on UTI diagnosis
Dr Amit Bishnoi

18. Pediatric UTI
• Over testing
• Over diagnosing
• Over treating

19. Sample Collection Methods
Newborns
Infants/toddlers
Older children
1. Bag Urine
2. Clean Cath (In and Out)
sample
3. CCMS
4. SPA

20. Technique for urine collection in
Newborn
CCU technique
Feeding
25 min interval
Suprapubic tap ~ 100 tap/30 sec
Lumbar paravertebral zones - 30 sec
Repeat till baby passes urine

21. Infants < 2 years
Quick-Wee method

22. Sample time
First void sample
Nitrites & proteins
Freshly passed
urine(2-4Hr)
Cells, leucocyte esterase
Get fresh sample if urine kept
> 1 hour - at room temperature
> 4 hour - in refrigerator

23. Urine dipstick (POC)
• Glucose 30 sec
• Ketones 40 sec
• Sp Gravity 45 sec
• pH 60 sec
• Nitrite 60 sec
• Blood 60 sec
• Urobilinogen 60 sec
• Protein 60 sec
• Leucocyte 2 min

24. Testing
• NITRITE : bacteriuria (GNB only)
False Neg - short bladder time (<4 hr);Vit C, pH < 6, high urobilinogen, high
Sp gravity, GPB (Staph)
• Leucocyte Estrase : Leucocytouria
False positive - lysed cells, prepucial skin material
False Neg - High Sp gravity,Ketones, Glucose, Drugs -
NFx,Cephalexin,genta,Vit C
• Leucocyturia
• Bacteriuria
Pearl -If urinalysis of fresh (less than 1 hour since void) urine yields negative leukocyte esterase and nitrite results,
1. NITRITES
2. LEUCOCYTE ESTRASE
3. LEUCOCYTE COUNT
4. GRAM STAIN

26. Diagnostic accuracy of clinical symptoms
• Prior history of UTI
• Temperature > 40*C
• Fever > 24 hour
• Jaundice
• Suprapubic tenderness
• Uncircumcised Male infant
Pearl: Clinically obvious source of infection decreases the likelihood ratio by half

27. Risk stratification
• Less then 2 months
• Any Fever with no obvious source of infection ( does not include URI)
• 2 months to 2 years UTICal
• 3 year and older
classical symptoms of UTI - dysuria, urgency/frequency, incontinence, abdominal pain/back pain, hematuria
Male > 3 year : rare
Adolescent girls : non-specific vulvovaginitis

28. Summary - Infant UTI Algorithm

29. Summary - Infant 2 mo -2 year

30. Mosquito Repellants –
Dr Shailesh Mehta MD Pediatrics

31. CDC , EPA, W.H.O P.E.S- APPROVED
for kids> 2months and pregnancy
PMD is the only herbal prep approved > 3yrs

32. NOT APPROVED BY –
CDC , EPA, W.H.O. –P.E.S
Inadequate efficacy and safety studies

38. ATOPIC MARCH
Dr. Manoj
can we halt the sequence ?

39. ATOPY : Increased IgE antibodies . Sensitization
`
Typical Sequence : Atopic Dermatitis AD > Food allergy > Allergic
Rhinitis > Asthma.
Prevelance of AD : World wide 0.3 – 20.5 %
India 0.01% -- 0.55 %
(ISAAC studies ,2013)
Onset of AD : 45 % First 6 months of life
60 % Initial 1st year .
Prevalence of Asthma/& Allergic Rhinitis in AD cohort : 30 – 66 % by 3 years
age
Compared to 8% of general population
Severity of AD …. Increases the risk.
Kapoor et al.

40. “Causal link” between Eczema late onset Atopic respiratory diseases !
Impaired Skin
Barrier
Ceramide.
Innate Immune
Activation
Dys-regulated
Immune response
Environment stimuli
Skin Inflammation.Allergic Sensitization

41. EPIDERMIS : primary defense & biosensor
Lower concentration of CERAMIDES in Infancy / AD
more permeable barrier
• Regular application of
Emollients
1ST week till 8 months
decreased occurrence of AD
by 50%
3 randomized
trials

42. Skin Barrier improvement intervention …. Primary prevention of Atopic march.
Mothers of high risk babies should be educated in prophylactic skin care.
Are we not under-rating the preventive value of traditional baby
massage which grandmothers are so fond of ?

43. Approach
to
First Afebrile Seizure

44. ILAE 2014

45. Detailed
History
First episode of Seizure
Rule out
seizure mimickers
Start AED & Evaluate
A B C
Manage Seizure
Treat provocation factor
Acute Symptomatic
Seizure
Remote Symptomatic
Epilepsy
Unprovoked Seizure
Check for Risk Factor
Evaluate ± Start AEDCounsel

46. Risk Factors for Recurrence
• Partial Seizure
• Abnormal EEG With Focal Epileptic Discharge
• Pre-existing Neurological Conditions
• Family History
• Prolonged first seizure
Dev Med Child Neurol. 2019 Jan;61(1):82-90
Pediatr Int. 2015 Aug;57(4):665-9.

47. Fever with loose motions: When to use
antibiotics?

48. Risk factors
Host related:
age<3 months
Malnutrition
Chronic underlying disease eg IBD
Immune deficiency eg AIDS, on Immunosupressives
Setting related:
Day care centres
Hospitals
Traveler’s diarrhoea (80% bact)

49. Clinical conditions that indicate antibiotic treatment
Condition Putative bacteria Suggested antibiotic
Dysentry Shigella
Yersinia
Campylobacter
Azithromycin
Ciprofloxacin
Fever, Inflammatory
markers increased
Shigella Azithromycin
Ceftriaxone
Prolonged diarrhoea Gram neg enterobacteria,
Clostridium difficile
Metronidazole
Septran
Antibiotic associated Clostridium difficile Metronidazole
Vancomycin
Traveler diarrhoea ETEC,EPEC Azithromycin
Ciprofloxacin
Toxic state Gram neg enterobacteria,
Clostridium difficile
Ceftriaxone
Cholera Vibrio cholerae Azithromycin
Doxycycline
Ciprofloxacin

50. Mesenteric Adenitis
in Children
Dr Amit Bishnoi

51. Introduction
• 1921, Brennemann Syndrome
• Mesenteric nodes - layers of small
mesentery along the terminal
ileum & ileo-caecal junction
• Classification :
A. Primary
(Nonspecific) :
Acute &
Chronic/Recurrent
B. Secondary :

52. Introduction
• Mesentric Nodes size (USG, Short axis view -AP) - I
• Isolated finding with no other obvious cause
• Group of nodes > 3 in number
• Children > 8 mm
• Adult > 5 mm
• LN > 4 mm - 4-64% of asymptomatic
• LN > 8 mm : 14-83% of symptomatic
• Seen in all children - asymp,symp,acute abd,
FAP/RAP, gastroenteritis

53. Introduction
• Age : Rare after 12 years of age
• MC : 5-8 years
• Most common
Differential Diagnosis :
Acute Appendicitis
Tubercular
Abdomen
• Most cases - self limiting viral illness
(MC - Adenovirus); 3-10 weeks
• Linked to reduced risk for ulcerative
colitis in adulthood

54. Symptoms
•Acute :
• Fever - MC
• Abdominal pain - diffuse > RLQ
• Loose stools
• URI like symptoms - accompanying or
antecedent
• Nausea/Vomiting - precedes pain
• Chronic:
• Recurrent pain abdomen

55. Examination
• Local :
• Normal or mild diffuse
tenderness
• RLQ tenderness +/- voluntary
guarding or rebound
tenderness
• Systemic :
• Rhinorrhoea, Congested
pharynx
• Cervical LAP - 20%

56. Diagnosis
• Diagnosis of exclusion :
• incidence of mesenteric
adenitis is rather low in
children presenting with or
without abdominal pain
• Need to rule various
important D/D - Constipation,
Appendictis, Intussception,
Merckle diverticulum, IBD,
Cystitis/UTI, testicular torsion,
ectopic pregnancy
• Yersinia enterocolitis - uncooked
or undercooked pork, tofu,
unpasteurised milk/milk
products contact with domestic
animal

57. Secondary Causes
• Enteric Fever
• Viral Gastroenteritis
• Yersinia
enteroclitica/pseudotuberulosis
• Mycobacterium
• Campylobacter
• Psoas abscess

58. Acute Appendicitis Mesenteric Adenitis
• Shorter history (1-2 days)
• Pain precedes vomiting
• Anorexia
• Guarding/Rigidity/Rebound
tenderness
• Usually absence of other localising
symptoms
• Leucocytosis - Neutrophilic; Higher
CRP values
• Slighter longer (4-5 days); recurrent
• Vomiting precedes pain
• Relatively preserved appetite
• Absence of guarding/rigidity/rebound
tenderness
• Concomitant Viral URI/congested
pharynx
• Leucocytosis - lymphocytic
predominance; Lower CRP values
USG with graded compression

59. • Abnormalities of the ileum are
most prominent in Yersinia
ileocecitis where as thickening of
cecum and ascending colon is
more prominent in campylobacter
ileo-cecitis.
• Tubercular mesenteric nodes -
matted/mass like, associated with
mesenteric thickening 15 mm or
more, omental cake, ileo-cecal
wall thickening

60. Treatment
• Acute non-specific mesenteric
adenitis - mostly viral, self limiting
• No
ANTIBIOTICS;
rule out acute
abdomen
causes
• NPO/IV
Hydration
• Pain
management
• Yersenia - First Line : Aminoglycoside
+ TMP-SMZ
• 3rd Gen
Cephalosporin/Tetracycli
ns/Fluroquinolones

61. Treatment
• Chronic/Recurrent :
• Wait & Watch - repeat USG 1-3 months
; if persistent symptoms with enlarged
nodes - adenitis is not a cause for the
pain and look for other etiologies or
FAP
• Rule out TB
• Undiagnosed Celiac - multiple nodes
with centrally necrotic mesenteric
nodes or in a K/C/O Celiac -
development of Lymphoma
• Whipple’s disease - Hypoechoeic
nodes ( due to fat rather than necrosis
)

62. Can we give empiric
antimalarials?

63. Case scenario-1
• 3 yrs old Chota Bheem lives in Chandigarh
• Fever upto 103 intermittant, since 5 days
• Chills and rigors present
• Active playful inbetween episodes of fever.
• No localising signs.
• On day 5 Cefixime by PP
• Hemogram and PLT count normal
• Urine routine normal. RDT Malaria Negative.
• Holiday trip to Mumbai 1 week back
• Should antimalarial be tried ?
• If yes then which antimalarial?

64. Case 1 Management- ICMR, WHO
• No antimalarials unless diagnosis confirmed
• RADT to be used where PS not available
• Positive Smear or RADT – START antimalarial
• Negative RADT – Confirm by PS
• Negative smear- Repeat 3 smears 6-8 hourly

65. Case Scenario -2
• Gully Boy 5 yrs old lives in a slum in Mumbai
• Fever since 5 days , upto 104 F
• Drowsy , sick looking
• Pulses weak, Low BP, tachycardia
• Pallor, mild splenomegaly
• RBS- 40 mg%
• Other blood reports awaited
• Should we start empiric anti malarial?
• If yes , then which antimalarial?

66. CASE 2 Management
• Complicated Malaria
• Do not wait for reports
• Start antimalarials empirically as per WHO/ ICMR
protocol
• Alter treatment accordingly when reports arrive

67. Tips for examining a child
• Dr Sandip Jain

68. 3 ‘devices’ that may change your practice

69. Wax removal – the easy way !

70. Removing Foreign Body from the nose

71. A BUBBLY THANK YOU!