basic information about h1n1 flu influenza infection in children

basic information about h1n1 flu influenza infection in children

Rational oral primary antibiotic selection in outpatient pediatric patients

1. What are the different oral antibiotics
2.what's the spectrum of oral antibiotics
3.what are the different pediatric outpatient issues
4.how to differentiate need for antibiotic in pediatric outpatient issues
5.what are the subjective and objective marker s
6.what are the possibilities for IV antibiotics
7.when do we needs to change or descalate
8.why complete dose and course and how to ensure same
9. How to guess the organism
10. How to judge the severity
11.RS GI SKiN CVS UtI examples



Continued...

posted from Bloggeroid

Hypovolemia in children

Its the common pathology that is coexistent with most deaths all over the world. Hypovolemia that is missed or undertreated gets into vicious cycle of reduced urine output and renal hypofunction that can never be improved without adding fluids.
Remember high fluids intake can eb washed of with diuretics but low fluids with vicious inotropic support can be killing.
Also hyperkalemia ie common coexistent terminal electrolyte issue around death.  Potassium supplements especially fruits often are needed for only dehydrated kids with low potassium.. but uts always better we treat them with hospital support than with potassium.
But fruit juices especially coconut juices can surely do harm for patients especially with kidney related issues who are at risk of developing hype kalemia.
Moral is... reserve fruits and juices for healed patients and not the sick ones.
Www.pediatricianonline.in

ERG or VEP?

Often blindness is associated in neuro metabolic diseases apart from hyperbarix oxygen damage in new borns to ocular infection s.

We follow retina assessment protocol for suspected retinal detachment in nicu or ventilator graduates..

For optic atrophy no obvious tests but a repeat check after three months following a heavy dose steroids helps doc call it irreversible.

In extensive retinal disease both ERG that is electroretinogram and VEP are likely to be abnormal.
In retinitis pigmentosa as in storage diseases ERG may be affected though VEP may be preserved.

Vice versa in macular degeneration VEP is affected and ERG May be intact.

For diseases like galactosemia and wilsons monitoring lens ofr cataract is important so is in steroid toxicity.

marcus gun jaw winking synkinesis

http://drpeds.blogspot.comhttp://funnytrivias.blogspot.comDr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

modified Rights classification of empyema

secrets of managing diaper dermatitis in children.. for doctors

Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

secrets of DD are out : let me end this discushion : remember these basic points.
 unless we know the cause treatment is useless. 
There are 4 main types of rashes that occur in this area.
 fungal,
 cellulitis,
 ammoniacal dermatitis and
 allergic or contact dermatitis. 
Barring zinc deficiency, PEM etc are mainly for chronic ones. 


now there is one single point to diagnose each of them.


 fungal has satellite lesion == look for them,


 cellulitis is tender to touch= feel for it,


 ammoniacal has must involvement of tip of penis or clitoris and has ammo smell often related to urealytic organisms,


 contact can be elicited by repeated use at friction points more often than in center.


 treatment is accordingly, 


fungal... prefer antifungal cream prefer mico for dry lesions, antifungal powder for wet lesions .


 bacterial == local and systemic antibacterials are must, 


ammoniacal needs soothing emolients with zinc and some antibiotic like nitrofurantoin,


 contact responds to emolients and at times steroids.


 common treatment for all is 
avoid diapers however tempting it may be.
 keep the area open till healing, 
donot rub but mop after a motion. 
avoid moisture as much and as often,
 fan the area.. 
remember calamine is fooling and use only for very mild.. to be or not to be cases. No references ...

childhood asthma in india need for modifying GINA guidelines for INDIA

http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

national treatment guidelines for malaria

http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

ring enhancing granulomas, vanishing CT scan lesions

http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

tumors,oncogenes,syndromes

http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

floppy infant syndrome

http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

failure to thrive approach

http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

FW: {Pediatric Doctors} Few formulas which might help doctors working in NICU

 

Dear Colleagues,

Its a common problem in NICU that due to hypoglycemia or hyperglycemia, we have to either discard the TPN or change the IVF mix. Its a huge loss to the hospitals. I made few formulas to change the dextrosity which I want to share with all of you.

1)Potdar's Neonatal formula to decrease the dextrosity of solution

Present volume-- PV ml
Present dextrosity – PD%
Desired dextrosity – DD%
ml of sterile water required— Y ml

Formula :-
(PV x PD) +(Y x 0) = (PV+Y) x DD

Y=PV(DD-PD)/DD ml of sterile water needed

Exp—
Weight of infant 1 kg
Total fluid required @100 ml/kg/day = 100(PV)
Present Volume—100 ml
Present dextrosity --- 20
Desired dextrosity—18
Ml of sterile water required—

= (100 x 20) + 0 = (100+Y) x 18
= 2000 = 1800 + 20 Y
= 20Y = 2000-1800
= 20 Y = 200
Y = 200/20
Y=10 ml of sterile water

OR

Y= PV(DD-PD)/DD

Y= 200/20

= 10 ml of water

This small amount of water may dilute the electrolytes. For this, either you can add electrolyte in same proportion or may increase the fluid rate to give this extra amount in set time if clinically
feasible.

2)Potdar's Neonatal formula to increase the dextrosity

Present volume -- PV ml
Present dextrosity – PD%
Desired dextrosity – DD %
ml of 50% dextrose required— Y ml

Formula :-
(PV x PD) +(Y x 50) = (PV+Y) x DD

Y= PV(DD-PD)/50-DD ml of 50% dextrose required

Exp—
Weight of neonate-- 1 kg
Total fluid required @ 100 ml/kg/day—100 ml (PV)
Present dextrosity --- 18%
Desired dextrosity—20%
Ml of 50 % dextrose required—

= (100 x 18)+ 50 Y = (100+Y) x 20
= 1800 + 50 Y = 2000 + 20 Y
= 50Y- 20Y = 2000-1800
= 30 Y = 200
Y = 200/30
Y=6.7 ml of 50 % dextrose.

OR
Y = PV(DD-PD)/50-DD
Y = 100(20-18)/50-20
Y = 200/30
=6.7 ml of 50 % dextrose

This small amount of dextrose may dilute the electrolytes. For this, either you can add electrolyte in same proportion or may increase the fluid rate to give this extra amount in set time if clinically feasible.

3)Making IVF mix with D10% and D 50% (or any two solutions of different dextrosity)
In many neonatal nursery IVF mix is made by adding sterile water and D 50%. Which is more costlier. We can make IVF mix by D10 and D50%.

Formula--

General formula for any two solutions with different dextrosity=

Total volume required= TV

ml of solution containing higher dextrosity(HD%)= X ml

ml of solution containing lower dextrosity(LD%)= TV- X ml

Desired dextrosity= DD

X ml = TV(DD-LD)/(HD-LD) ml of HD in TV

ml of LD in TV = TV- X ml

exp-

Total volume required is 100 ml

Desired dextrosity is 16% and we have D10 and D50%

HD=50%
LD= 10%

ml of D 50 (X ml) = 100(DD-10)/(50-10)

ml of D 50% ( X ml) =100(16-10)/40 ml

= 600/40 ml
= 15 ml

ml of D10%= 100-15=85 ml
 

 

---

Manage your finance and manage money through MSN Money Special Drag n' drop

Yale Observation Scale

Yale Observation Scale (Mc Carthy Pediatrics)



Indications

1.Assessment of febrile child ages 3-36 months

2.Predicts serious infection (Occult Bacteremia)

3.Quantifies "Toxic Appearance" in children

Interpretation
1.Score = 10 :                        Incidence serious illness: 2.7%
2. Score = 11-15                    Incidence serious illness: 26%
3. Score >16                          Incidence serious illness: 92.3%

Scoring

Quality of Cry

Strong or No cry: 1

Whimper or Sob: 3

Weak cry, Moan, or high pitched cry: 5

Reaction to parents

Brief Cry or Content: 1

Cries off and on: 3

Persistent cry: 5

State variation

Awakens quickly: 1

Difficult to awaken: 3

No arousal or falls asleep: 5

Color

Pink: 1

Acrocyanosis: 3

Pale, Cyanotic, or Mottled: 5

Hydration

Eyes, skin, and mucus membranes moist: 1

Mouth slightly dry: 3

Mucus Membranes dry, eyes sunken: 5

Social Response

Alert or Smiles: 1

Alert or brief smile: 3

No smile, anxious, or dull: 5

------------------------------------------------------------------------------------

www.doctorchild.com



Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA

Pharyngitis

its true that most pediatric pharyngitis (below 2 yr age) are viral in origin, and bacteria including streptococci are commonly grown from pediatric throats even though the child is asymptomatic. So it becomes relatively unnecessary to perform throat cultures.

"Viruses are isolated in approximately 40% of cases and include rhinovirus, adenovirus, parainfluenza virus, coxsackievirus, coronavirus, echovirus, herpes simplex virus, Epstein-Barr virus (mononucleosis), and cytomegalovirus. Primary bacterial pathogens that account for approximately 30% of cases of pharyngitis in children include GABHS (common), group C streptococci (uncommon), group G streptococci (uncommon), Neisseria gonorrhoeae (uncommon), Corynebacterium diphtheriae (rare), and Corynebacterium hemolyticum (extremely rare)."(ref:http://www.emedicine.com/EMERG/topic395.htm)

Where as its easy to suspect a viral aetiology if some of the symptoms and or signs are present; viz: typical prodrome, cold, conjuctivitis, rhinorhea, wheezing etc; its absence doesnt truly mean its bacterial in origin.

Bacterial sorethroat similarly has some of the characteristic findings like white patch/ granular inflammation /microabscess / associated acute lymphnode enlargement / lymph node tenderness, sinus tenderness, scarlet rash / membrane etc. But absence of these findings may help one suspect strongly a nonbacterial infection.True; nothing is certain.

The real reason to treat pharyngitis emperically and urgently; is the risk of its sequalae like glomerulonephritis, rheumatic fever and kawasaki disease.These risks are always there with even asymptomatic streptococcal pharyngitis; but documentation of streptococcal throat culture negative after therapy gives some clinical satisfaction in curtailing at least some of GABHS disease.

I prefer to stick only to conservative therapy in throat infections, mainly because most of throat and related infections in children below 2 years are viral origin and in children above 2 years, bacterial infections usually localise and also give enough time to observe/evaluatethe course of disease.

The therapy that works best is soothing normal saline nebulisation for throat relief, added to paracetamol for relief from fever and malaise for 2-3 days; keeping a close watch on development of any diagnostic signs for viral /bacterial aetiology, and if required, antibiotics; after a CBC / ASLO / culture as per the regional recommendations.

====================================

http://drpeds.blogspot.com

Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA

Mental retardation a video review

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view the video full screen



Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA

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Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA

CCF and shock in children

It may sound very surprising but i need to combine these contrast topics to discuss together. As many a times I come across situations where the treating docs even residents and pediatricians alike have made a common mistake of misunderstanding one as another and created problems for the patients and themselves.

How is it possible?
Shock is a situation caused by disparity between fluid volume and capillary bed manifesting as poor pulse and blood pressure.
CCF or congestive cardiac failure is a condition caused due to increased preload following venous overload or cardiac hypo function.

In late stages both these cases can overlap, as shock can cause cardiac dysfunction and cardiac dysfunction due to CCF can lead to shock.

And thus most patients coming in late stages to emergency room are falsly interpreted as shock or CCF especially when the facility for JVP CVP BP measurements is not available or faulty. ( yes its likely- as BP measurement varies with age size of cuff and the person who is taking BP and there are no clear cut levels in any area or age for lowest normal BP. Also CVP may be difficult due to venous access in shock. The CVP reading change with movements , intervention and position of CVP catheter tip which may require an X-ray to confirm.)

In addition the confusion arises due to possibility of presence of congenital heart disease or carditis in children. if the child had a chronic heart disease, its more likely that the decision fo CCF si very often made, as the baseline hepatomegaly and cardiomegaly as a part of chronic heart failure is wrongly interpreted as acute CCF.

Similarly, as in acute carditis or sepsis, raised JVP the only important clinical sign apart from cardiomegaly, is difficult to examine and interpret especially in infants, the failure of heart is interpreted as shock.

As both these conditions present with common findings at some stage
: Tachycardia, poor or weak pulse and low blood pressure and desaturation.
They are easily confused unless an expert decides from various other clinical markers.

why do we need to discriminate the two: CCF and shock?
Because, the treatment differs.
for CCF the main therapy is volume reduction diuresis and judicious blood transfusion and digoxin. And rarely inotropes.

And in shock its fluid pushes and inotropes.

A wrong judgment will take you in wrong direction with vicious events.


Some basic understandings will help not making this mistake:

Hyponutrition, hypovolemia and shock is a more common entity than fluid overload or CCF in any disease situation. Even empirically patient will be in shock than CCF. Except 2.

CCF is more common in association with sever anemia and congenital hearts in infancy mainly below 6 months age. Please confirm the presence of significant hyper dynamic circulation / chest movements /PH with acute cardiomegaly. No cardiomegaly means no CCF. Severe anemia may be a misunderstanding of poor perfusion, please wait till the Hb report before transfusion.

The most important finding that’s easy to discriminate is liver tenderness and JVP when measured accurately. Shock will never have liver tenderness. Liver tenderness without raised JVP or cardiomegaly is more likely to be hepatitis than CCF. Acute liver tenderness is an important sign of fluid overload especially in managing dehydrations and shock.

Presence of creptations is very important sign provided one gets bilateral symmetrical Velcro crackle in basal interscapular area. If you get asymmetric crepts, its patchy pneumonia and if you get crepts all over chest, its ARDS or pulmonary bleed in shock.

Measurement of CVP is by far the most important and standard criterion to discriminate shock and CCF. This may not be possible easily in many developing countries. But an attempt should always be made to get a CVP line in all cases of suspected shock and CCF. CVP more than 10 is surely CCF and CVP less than 5 is surely shock.

The conditions where shock and CCF coexist more often are cardiomypopathy, massive myocardial infarctions, sepsis with carditis and aortic stenosis and other obstructive lesions of heart. In such cases the management is highly judicious giving adequate to fewer fluids with maintenance of BP to lowest normal to perfuse periphery and judicious use of diuretics with calculated fluid and salt intake. Most care should be taken not to combine diuresis with fluid restriction; and avoiding peripheral inotropes that will do only harm by increasing peripheral resistance however small dose it is.

==================================================================

read http://www.nhlbi.nih.gov/health/dci/Diseases/hyp/hyp_whatis.html
read aug 2008 IJP symposium septic shock Indian journal of pediatrics


http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

http://drpeds.blogspot.com

http://funnytrivias.blogspot.com


Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA

experience of tetanus cases from mumbai

tetanus once considered to be a deadly medical disease, has come a long way in 20th century, as an easily preventable and effectivey curable disease. So much so that its incidence has disappeared from developed countries.
Even though least cases are seen these days due to effective maternal and childhood immunisation programs; in many areas of developing countries like India, do have significant number of patients presenting as tetanus to tertiary care centers. And few of them have mortalities too.

The once famous Jog and patel clinical score criteria based on fever, tachycardia, number and areas of spasm / trismus; and autonomic disturbances is less often used by many pediatricians; and those who use modify as per their covenience, as the dosages proposed according to clinical score; can be as high as 60 to 80 mg/kg of oral diazepam which is usually not supported by standard textbooks. And also the clinical scores do change very often with or without treatment, a titration of oral dose accordingly doesnt appear a logical solution; as oral absorption of diazepam is erratic. ref 1 2 3

What is more important in management of tetanus is correct diagnosis. A lot many cases are wrongly diagnosed as tetanus; as many people are not awrae of what is trismus and how to check for it. Trismus or lock jaw is a clinical condition that is considered very diagnostic of tetanus; ( and as investigations are often useless in diagnosing tetanus, trismus serves as the sole gold standard diagnostic criteria for tetanus); it is characterised by forecful spasm of jaw muscles with inability to open mouth even under mild pressure; and it is demosntrated in best way by introducing a tongue depressor in mouth; rather attempting to do so; will fail to open mouth. Its very prudent to divert child's attention so that voluntary spasms dont coexist.

Tetanus can be diagnosed in absense of trismus from spasms, rigidity of neck trunk limbs and abdomen; with normal sensorium in a child witha focus of infection and / or history of nonimmunisation.

A wrong diagnosis of trismus will take the child for wrong line of management and vicious cycles of diazepam therapy; and lrolonged hospital stay with addition of multiple medicines; and avoiding all further tests; because once a doc makes diagnosis fo tetanus; usually others dont question it.

How does one make a wrong diagnosis of trismus?
1. false interpretation of voluntary spasm
2. examination by inexeperienced doctor
3. patient may have a seizure and may be interpreted wrongly
4. it can be associated with contradictory neurological signs
5. altered sensorium almost rules out tetanus, unless its following severe hypoxia; which is very rare.
6.if the patient presents to hospital after receiving diazepam and one has no clue to check for trismus


So please reecheck the trismus again, preferably by a senior too; and look for supprtive signs / spasms or contradicting neurological signs.

Another important thing after diagnosis of tetanus, is curtailing a spasm at the earliest. if we donot curtails spasms, they add on to precipitate sever bronchospasms and death.

a spasm should be preferably curtailed only with parenteral diazepam; preferably IV ( diluted with blood) or Intramuscular preferably in deltoid; or per rectal (when IV access is not possible); and never oral.

dose of parenteral or oral diazepam given in most books in 0.2 to 1 mg/kg / dose; which in cases of tetanus appears to be refractory. midazolam doesnt prove promising; and has no benefit in tetanus cases.
Remember diazepam almost never causes of respiratory depression even in higher doses (unless added with another drug like phenobarbitone). Almost all cases of diazepam poisoning recover satisfactorily in a week. ALso, the common morbidity follwoing diazepams is mostly due to its cumulative sedation and vasodilation causing intracranial bleeds.

In tetanus, one may need doses as high as 1-5 mg/kg bolus or tetanus preferably in divisions every 10 minutes (for those who are scared of large dose). to curtail an acute spasms. A spasm can also be controlled by giving muscle relaxants or by causing paralysis; but that make sthe child ventilator dependant.. ( and many are scared of intubations in tetanus cases and go for tracheostomies adding another morbidity.

I had used upto 10mg/kg/dose boluses without causing any problems for curtailing the spasms. Only svere bronchospasms may require high dose diazepam.

Other ways, are to start a low dose diazepam infusions after a bolus diazepam; the infusion are usually 0.2mg/kg/hr for no more than 2 days. dose can be increased gradually; till spasm, but once spasm is controlled for an hour, please taper the diazepam drip rate hourly to avoids intracranial bleeds. switch over earliest to oral or rectal diazepam therapy.

oral diazepam therapies are started at doses of 40, 60 and 80 mg/kg/day in mild , moderate amd sever tetanus respectively. With time, the doses have come down to 20. 40, 60 respectively.

The absorption is errartic with oral. addition of antacids hampers absorption and vomitting and gastritis are frequent complications but are easily treatable.

In the past various antibiotics have ben used for various reasons, but as the clostridia are anaerobes, metronidazole as a single drug chemotherapy usuallky suffices unless another bacerial contamination or pus is documented.

Other CNS dperessants like phenobarbitone, chlorpromazine and chlorzoxazone have been trie in past with erratic regimens without any evidence based benefits. Baclofen is a safer switch over drug due to safety of relaxing mainly skeletal muscles. its action usually is seen by 3rd day, dose range form 0.2 to 1 mg/kg/dose 3-4 times a day.

Tracheostomies especially emergency ones have been associated with significant morbidities.

usually the spasms get controlled in 3-5 days, diazepam can be started tapering once 3 days spasm and rigidity free are observed, but needs to be titrated judiciously. Sometimes spasms may recur again to increase the dose of diazepam. ALl can settle in 2- 4 weeks.

Not to forget, the most important therapy in tetanus management is Tetanus immunogolbulin in high dose to titrate with tetanospasmin; usually 500IU in newborns, 1500IU in infants and 2000 to 3000 IU in children to adults; alongwith primary tetanus immunisation fo child and family.


http://www.pedsccm.org/RARE/Tetanus.html
Lorazepam may be preferable . Limited experience with propofol ,Dantrolene Baclofen Further clinical studies needed. Prompt recognition and treatment of autonomic dysfunction are important in reducing the mortality in this disease.

Author Dr Kondekar Santosh is a pediatrician at Seth G S medical college at KEM Hospital Mumbai india. All of the above opinions are his personel opinions out of personel experience, for more details write to santoshkondekar@kem.edu .