Dr. Gaurav Gupta - Should you be buying an E-bike this Diwali? Dr RP Bansal- Feeding difficulties in the newborn Dr Nivedita- Tips on how to Continue Breast Feeding Dr Ridhi- Teething tips Dr Arushi - First afebrile seizure Dr Amit - Mesentric lymphadenopathy Dr Gunjan - Acute events following immunization plus update on BCG adenitis Dr Sandip Jain- Tips for examining children Dr Diljot - Mefenemic acid as an antipyretic Dr Jaskaran- colicky infant : knowledge , attitude and practices Dr Shailesh - School se chutti kitne din karayein ? Dr Gaurav- Is it oral Herpes? Visual Quiz

1. What Nelson Forgot
5th Edition
11th Oct, 2019

2. Scope
• 10 questions,
• < 10 mins discussion per question
• Immediate diagnosis / treatment
• Minimum slides, Optional References
• START when 10 people are present after 830 PM, incl at least 1
speaker
• FINISH when a majority decides ….

3. Scope
• Please note that this initiative is to discuss common issues in
practice for which sometimes there are no concrete guidelines.
• It's an open forum to discuss personal experience, expertise
and knowledge with or without references.

4. Topics
• Dr. Gaurav Gupta - Should you be buying an E-bike this Diwali?
• Dr RP Bansal- Feeding difficulties in the newborn
• Dr Nivedita- Tips on how to Continue Breast Feeding
• Dr Ridhi- Teething tips
• Dr Arushi - First afebrile seizure
• Dr Amit - Mesentric lymphadenopathy
• Dr Gunjan - Acute events following immunization plus update on BCG adenitis
• Dr Sandip Jain- Tips for examining children
• Dr Diljot - Mefenemic acid as an antipyretic
• Dr Jaskaran- colicky infant : knowledge , attitude and practices
• Dr Shailesh - School se chutti kitne din karayein ?
• Dr Gaurav- Is it oral Herpes? Visual Quiz

5. Should you buy an E-bicycle
this Diwali?
Dr. Gaurav Gupta

6. What is an E-bike?
• Everything a normal cycle has…
including gears,
• Also has rechargeable batteries, a motor
(40 km to charge- 1 Unit, 5 hours to full
charge)
• And controllers

7. Market
Increasing worldwide
• 2 lakh (2008)  5 lakh (2009)  7 lakh
(2010) e-bikes sold in Europe
• China is world leader, (> 10 billion USD
sales)
• USA, India & Netherlands are some
upcoming countries
• The number of electric four wheeled
vehicles in circulation is around 4
million. But the number of electric
bikes in circulation is over 35 million.

8. E-cycles
Pros
The HEM Effect TM ?
• Health
• Environment
• Money
• Great for the ‘less fit’ – range
• Any pains/ aches
• ‘No sweat’ commute to clinic
• FUN FUN FUN !
Cons
• Early Adopter technology
• Increased maintenance
• Expensive, heavy

9. Call to action
It’s FUN!
Freedom!
Save the Environment!
Looks COOL!
Chandigarh is India’s
Cycling City

19. First afebrile seizure
Dr. Arushi, Asst. Prof, Pediatric Neurology, PGI

20. A physician managing a child following a first afebrile
seizure should try to answer five questions:
1. Was the episode an epileptic seizure?
2. What is the cause of the seizure?
3. What investigations should I do?
4. Does the child require treatment?
5. What else should I think about?

21. Red Flags
• Head injury with delayed seizure
• Developmental delay or regression
• Headache prior to the seizure
• Bleeding disorder, anticoagulation therapy
• Drug/alcohol use
• Focal signs

22. Differential diagnoses
• Arrhythmia
• Breath holding spell
• Self stimulation episodes
• Vasovagal syncope with anoxic seizure
• Non-epileptic paroxysmal disorder

24. BREAST FEEDING: EARLY PITFALLS
Dr. RP Bansal

25. Poor initiation: improper latching
• Baby was born 3.5 kg, lost weight to 3.1 kg, regain was very slow;
she weighed almost same 3.5 kg on 18th day. Was EBF.
• The mother was overanxious, was feeding the baby very frequently
but wasn’t making proper contact. Baby used to suck vigorously but
she was not getting a good supply. The mother used to get
impatient soon, the baby was fussy all the time.
• The mother was asked to give ample time to the act of feeding, was
explained the ‘latching’, an occasional spoon feed was suggested
daily and was called after a week.

26. Cntd.
• The baby gained a good 300 Gm in the next 8 days.
• Never looked back.
• Spoon feed was stopped.

27. The milk on the back is better!
• Arnav was born 3.3 kg and brought for vaccination at 45 days. The
mother was not satisfied with his growth. He weighed 4.3kg, was
taking breast feed almost every hour, passing 15 semi loose stools
in 24 hours and was a cranky baby.
• On examination, he was having some perianal excoriations. On
asking, the mother told that she was giving EMB, fed the baby from
both breasts in one sitting.
• The mom was explained about the importance of hind milk and
asked to let one breast empty before offering the second one.
Called after 10 days.

28. Hind milk did wonders!
• The baby gained a good amount of weight,400 gms in 10 days.
Number of stools decreased to 5-6 a day, excoriations
disappeared, the baby started sleeping more peacefully.
• The mother was also sleeping more peacefully!

29. COUNSELING FOR
CONTINUATION OF
BREASTFEEDING
Dr Nivedita (MD pediatrics)

30. Why this discussion
Common scenerio in opd
Mother starts and wants to breastfeed according to advise received in
antenatal period and at discharge. Comes at 6 wk vaccination visit –Is
giving mixed bottle and BF and gradually over next visits we have an
exclusively bottle fed baby.
FACTS
95% indian mothers start breastfeed initially
Exclusively breastfed – 54%
Most of them quit in early wks due to
1) Perceived low milk supply
2) Family pressure
3) Find it difficult

31. How can we help- Tips
Breastfeeding guidance visit
◦ Around 3 wks after discharge
◦ Supervision of position (of mother too)
◦ May be difficult but why a must for baby
◦ GOOD LATCH IS THE KEY
Adequate drainage of breast
Foremilk, hindmilk
◦ Dedicated staff, written handouts,videos

32. Counseling of father and dadi-nani
◦ Pet nahi bharta ,Rota rehta hai
◦ Susu?.......... Mint mint mein
Focus On
Adequacy of breastmilk
(Weight gain, urine output)
Crying is normal for babies
Hunger cues
Dangers of bottle feeding

33. Low milk supply ?
◦ Adequate drainage of breasts
Position, latch
Increase time on breast
manual expression, breast pumps(sick baby)
◦ Self breast massage
◦ Relaxation, Diet, hydration
◦ Skin to skin, KMC
◦ Galactogouges
last resort
Not much research (level III evidence)
shortest possible time

34. Thank you

38. • Gently rubbing the gums with a
Clean finger
Small cool spoon
Moist gauze pad
• Let baby chew on refrigerated vegetables like
carrots
• Use of teethers – solid rubber or silicon, can be
refrigerated. Avoid ones containing water.
• Use Paracetamol if pain or inflammation severe.

39. Not recommended
• Benzocaine or Lignocaine preparations or teething gels: risk of
seizures, methemoglobinemia
• Teething necklaces and bracelets: risk of strangulation and
choking
• Homeopathic preparations: contain Belladona, caffeine and
not safe for babies

40. Mesenteric Adenitis
in Children
Dr Amit Bishnoi

41. A. Primary (Nonspecific) : MC Children < 15 years
• Acute
• Chronic/Recurrent
B. Secondary :
• 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

42. Symptoms
• Acute :
• Fever - MC
• Abdominal pain -
diffuse/periumblical > RLQ
• URI like symptoms - accompanying
or antecedent (20-30%)
• Nausea/Vomiting - precedes pain
• Loose stools : if prominent suspect
zoonotic infection (Yesinia/Non-
typhoidal salmonella)
• Chronic :
• Recurrent pain abdomen

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

44. • Most common Differential Diagnosis :
• Acute: Acute Appendicitis ; Intussception
• Chronic :Giardia Lamblia, Tubercular
• Most cases - self limiting viral illness (MC - Adenovirus); 1- 4 weeks
• Linked to reduced risk for ulcerative colitis in adulthood

45. Diagnosis
• Diagnosis of exclusion : Pain
• Need to rule various important D/D - Constipation,
Appendictis, Intussception, Merckle diverticulum, IBD,
Cystitis/UTI, testicular torsion, ectopic pregnancy
• Yersinia enterocolitis/Salmonella - uncooked or undercooked
pork, tofu, unpasteurised milk/milk products contact with domestic
animal

46. Acute Appendicitis Mesenteric Adenitis
• Age older children
• Shorter history (1-2 days)
• Pain precedes vomiting
• Anorexia
• Guarding/Rigidity/Rebound
tenderness
• Usually absence of other localising
symptoms
• Leucocytosis - Neutrophilic; Higher
CRP values
• Age younger children
• 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

47. Treatment
• Acute non-specific mesenteric adenitis - mostly viral, self limiting
• No ANTIBIOTICS; rule out acute abdomen causes
• NPO/IV Hydration
• Pain management
• Antibiotics : Giardia/Zoonotic -Yersinia or
nontyphoidal salmonella

48. 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

49. Adverse events following immunization
BCG Adenitis Update
Dr. Gunjan

50. Case
• 6 week female, weight 4.8 kg.
• Birth weight 2.5 kg, no complications
• H/o URI 1 week back which had subsided by now
• Top feeds but accepting well and gaining weight.
• Vaccinated 40 hours back
• Came with decreased feeding from morning
• O/E - HR - 160/min RR - 75/min, SpO2 - 80% RA, SCR ICR +
• RBS - 90mg/dl
• Respiratory failure and referred

51. Vaccine Reactions
• Vaccine Product related
• Vaccine quality defect related reaction
• Immunization error related reaction
• Immunization anxiety related reaction
• Coincidental event

52. Minor Reactions
• Usually within a few hours of injection.
• Resolves completely.

53. Severe reaction
• Usually do not result in long-term problems.
• Can be disabling.
• Are rarely life threatening.
• Seizure
• Allergic reactions

54. Serious Adverse Event
Any untoward medical occurrence that at any dose causes-
• Death
• Requires inpatient hospitalization or prolongation of
existing hospitalization
• Results in persistent or significant disability/incapacity
• Life-threatening.

55. Vaccine Reaction Onset Interval Frequency per doses
given
BCG Fatal dissemination of
BCG infction
1-12 months 0.19 - 1.56/ 1000000
OPV VAPP 4 - 30 days 2-4/1000000
DTP Prolonged crying and
seizures.
Hypotonic Hyporesponsive
episodes
0 - 24 hours <1/100
<1/1000 - 2/1000
Measles Febrile Seizures
Thrombocytopenia
Anaphylaxis
6-12 days
15-35 days
1 hour
1/3000
1/30000
1/100000

56. Fainting Anaphylaxis
Onset Immediately 5 - 30 min
Skin Pale sweaty cold clammy Red raised rashes
Respiratory normal to deep obstruction
HR Bradycardia tachycardia
GI nausea/vomiting abdominal cramps
CNS transient loss of conciousness no loss

57. Anaphylaxis
• ABC
• Epinephrine 1:1000 IM into the anterolateral thigh, dose -
0.01 mg/kg (maximum dose 0.5 mg)
• Reporting

58. • Back to case

59. BCG Lymphadenitis

60. What is sometimes done “ Myths”
• Start antibiotics
• Start ATT
• Start only INH
• Evaluate with Mantoux test and Xray chest
• I and D
• Excision

62. Take Home Messages
• Vaccine related adverse event should be anticipated
• Prepared for immediate management in clinic
• Referred in time
• Reporting
• BCG adenitis - leave it alone

63. Tips on examining children
• Dr. Sandip Jain

64. Infantile Colic:Knowledge, Attitude and
Practices
Dr Jaskaran Singh Sawhney
Consultant Neonatology &
Pediatrics
Bedi Hospital

65. Knowledge :what we know
• Incidence :8-40%
• Multifactorial etiology
• Natural history
• Definitions :
– Wessels Criteria – “3”
– Classified as FGID under ROME III ->IV

66. Attitude
• Parents
 Impending Catastrophe
 Maternal depression
 Naani/dadi ??
 Gripe water
• Doctors
 No EBM guidelines
 Need to rule out organic causes
 Need to find “Ram Baan ilaj”

67. Practices : what works & what doesn’t (evidence)
Intervention evidence Practically!
Semethicone Doesn’t work Most widely used
Dicyclomine Not recommended for <6
months age
Very often used
Cimetropium bromide Poor quality Often used
Probiotic (L.reuteri) Good evidence(metanaysis
of 6 rct’s)
Costly, not proven in non
breast fed babies
Gripe water Not recommended Suggested often by family
Lactase drops Small studies : positive
results
Seldom used
Fennel seeds preparation Good effectiveness, but
heterogenous studies
Grandparents favourite
Maternal diet Poor evidence May be tried , especially
with h/o atopy
Phyhsical maneuvers Poor evidence May be tried
Parental counselling Consistent results Gold standard !!

68. Thank you !
• Asking for your blessings and support for new venture :
2 bays SCF No 4, sector 20 C , Chandigarh

70. Doctor school leave certificate de do

72. Infective period?

73. School leave till lesions crusted- 7 days

74. Apki bukhar ki dawai se rashes ho gaye

75. No chutti needed

76. Mouth Ulcers – Visual
Diagnosis Quiz
Dr. Gaurav Gupta
Acknowledgement: Dr. Sumeet Rajpal, Pediatric Dentist !

77. To identify 3 things
• Herpetic Gingivostomatitis
• Aphthous Ulcer
• Herpangina

79. Herpangina
Back of tongue &
Tonsillar Pillars,
Painful Swallowing

80. Herpetic Gingivostomatitis
• On “attached
gingiva” like gums &
hard palate,
• Also on lips &
tongue,
• Multiple small
blisters, raised edges
yellowish superficial
base

81. Aphthous Ulcer
• Deeper, Punched out, more in the
vestibule,
• Red borders
• Greyish base may coalesece,
• Unlikely on tongue unless traumatic