Thursday, 26 November 2015

Paediatric updates

Pediatrics Important one-liners & latest points from Nelson 20th ed for quick revision.

- Absence seizures to be treated with ethosuximide, as effective and less toxic than Valproate. Ethosuximide is more effective than lamotrigine. Lamotrigine & Valproate are more effective in atypical absence seizures/absence seizures associated with GTCS.
- In a preterm neonate at risk for RDS, CPAP started at birth is as effective as surfactant therapy & is the approach of choice for initial management in delivery room. In other words, first step in management of suspected RDS is CPAP. (No difference for mild, moderate or severe HMD).
- Indications to start mechanical ventilation in neonates & infants:
1. Arterial blood pH <7.20
2. Arterial blood pCO2 of 60 mm Hg or higher
3. Oxygen saturation (SpO2) <90% even at inhaled oxygen concentration of 40-70% & CPAP of 5-10 cm H2O.
4. Persistent apnea
Points 1, 2 and 3 are measures of respiratory failure in infants and children.
- A major breakthrough in Cystic Fibrosis therapy is IVACAFTOR, a small molecule potentiator of the CFTR mutation, G551D. Available as oral therapy in CF patients with G551D mutation (seen in 5 % patients). Improves FEV1 by 10%, decreases pulmonary exacerbations by 55% and also decreases sweat chloride levels. Given only at or above 6 yrs of age.
- Most common complication of pancreatic enzyme replacement therapy is colonic strictures.
- Hypoglycemia in neonates: Random whole blood glucose less than 45 mg/dl. (AIIMS-WHO definition). Any value below 55 should be viewed with suspicion. Hypoglycemia in infants and children is random whole blood glucose below 55 mg/dl. (Nelson 20th ed )
- MC symptom of hypoglycaemia in neonates is jitteriness & tremors.
- MC form of childhood hypoglycaemia is Ketotic hypoglycaemia, seen due to inadequate feeding. More common in malnourished with intercurrent illness.
- A new potential treatment, but still under investigation in Duchenne’s muscular dystrophy is use of antisense oligonucleotide drugs. Two drugs effective: Drisapersen & Eteplirsen. Both are exon-51 skipping antisense oligonucleotides, that can produce a shorter but potentially functional dystrophin protein.
- Microorganisms causing Infective endocarditis in children: Viridans streptococci, followed by Staph aureus are most common. Staph more common in no underlying heart disease, whereas viridans more common in children with underlying heart disease who undergo invasive dental procedures. Pseudomonas and Serratia more common with IV drug abuse & Coagulase negative Staph more common in those with indwelling central venous catheter. Fungal IE seen after open heart surgeries.
- Children with RHD: Mitral insufficiency is more common than Mitral stenosis (rarely seen before adolescence).
- Corrective surgery in TOF is done as soon as possible in TOF presenting early or having frequent cyanotic spells. For well tolerated TOF, age of corrective surgery is between 4 to 6 months of age. Palliative surgeries less common now.
- Right sided aortic arch seen MC in TOF, followed by Truncus arteriosus.
- MC cause of sudden cardiac death in children is valvular AS
- MC cause of sudden cardiac death in adolescents is HOCM
- Duration of antibiotic therapy in post neonatal & childhood meningitis has been decreased to 10-14 days maximum. For meningococcal meningitis its as short as 5-7 days and for H. influenzae its 7-10 days. 
- Streptococcus milleri is now MC organism causing brain abscess in children (more than Staph aureus). 
- HSP is MC vasculitis in childhood (Yes! Nelson finally says it clearly!)
- MCC of hematuria/gross hematuria in children is UTI (Overall)
- MC glomerular cause of hematuria in children is Post streptococcal GN
- Microscopic hematuria is rare in UTI. Recurrent hematuria raises suspicion of IgA nephropathy.
- The primary immunodeficiency disease with excellent prognosis even without specific therapy is Myeloperoxidase (MPO) deficienc

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