UF Service Trips Common Clinical Issues in Children

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UF Service TripsCommon Clinical Issuesin
Children

• Rob Lawrence, MD
• Pediatric Infectious Diseases

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OutlineObjectives

• An Approach to Diagnosis
• Growth / Development / Anemia
• Abdominal Pain / Diarrhea / Intestinal parasites
• Dengue / Malaria
• TB

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Approach to Diagnosisin Resource Poor Settings

• Ethics ? treat them as you would every patient,
  including sensitivity to cultural issues.
• Emphasize history and physical diagnosis to get
  to the diagnosis.
• Differential Diagnosis ? common/endemic gt
  urgent/criticaltriage gt treatable.
• What are you set up / prepared to manage?
• Empiric therapy ? lower threshold, need for
  follow-up.
• Follow-up within their health system education
  which is culturally appropriate.

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Growth, Development and Anemia

• Growth WHO Child Growth Standards Multicent
  re Growth Ref. Study (MGRS) Stunting, wasting,
  malnutrition
• Development Assessment Tools Observation
• Anemia Age, WHO standards Correlation with
  IQ, development and association with
  intestinal parasites
• Breastfeeding WHO Recommendations MGRS
  standards, potential

AHRQ report 153 -07-E007 www.ahrq.gov
Breastfeeding More than just good nutrition.
Lawrence RM Peds in Rev 201132267.
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Growth

• Stunting

• Underweight

• Height-for-age is less than -2 SD (below the
  mean)
• Chronic undernutrition - retards linear growth

• Weight-for-age is less than -2 SD (below the
  mean)
• Inadequate nutrition over a shorter period of
  time
• Linear growth maintained
• Head circumference growth still OK (spares the
  brain)

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Growth

• Wasting

• Severe Wasting

• Weight-for-height less than -2 SD (below the
  mean)
• Acute malnutrition with probable
  micronutrient deficiencies
• Increased risk of infections, diarrheal disease,
  death
• Odds ratio of mortality 2x mortality risk for
  children gt -1 SD

• Weight-for-height less than -3 SD (below the
  mean)
• Severe acute malnutrition
• Odds ratio of mortality 9x mortality risk for
  children gt -1 SD

Black RE et al. Lancet 2008, 371243-60. Maternal
and Child Undernutrition Study Group
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Kwashiorkor

• Growth Failure
• Wasting muscles
• Edema abdomen, scrotum, feet
• Hair changes
• Mental changes / activity
• Dermatosis
• Appetite diminished
• Anemia
• Fatty lliver

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Principles of Treatment forSevere Malnutrition
Step Days 1-2 Days 3-7 Weeks 2-6
1. Hypoglycemia -
2. Hypothermia -
3. Dehydration -
4. Electrolytes
5. Infection
6. Micronutrients (no iron) (no iron) (with iron)
7. Cautious feeding -
8. Catch-up growth - -
9. Sensory stimulation
10. Prepare follow-up - -
Ashworth A et al. Child Health Dialogue Issue 3
4, 1996 10 Steps Guidelines for treatment of
Severely Malnourished Children
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Malnutrition

• Calories
• Protein
• Micronutrients Vitamin A Iron
  Iodine Zinc

Disease Control Priorities in Developing
Countries Stunting, Wasting and Micronutrient
Deficiency Disorders Caulfield LE, Richard SA et
al. Chapter 28
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Micronutrient Deficiency
Deficiency Consequences Foods Supplementation
Vitamin A Night blindness Infection - mortality Animal foods fat Liver, milk, egg yolks Dk green leafy vegetables, oil, Carotenoids, BM breast milk Capsules, Fortification of salt, flour, sugar, rice, butter BM tri-vi-sol iron
Iron Anemia Neurologic impairment Immune deficiency Meat, beans, Breastmilk (BM) Fortified cereal, salt, sugar Rx - 3 months
Iodine Goiter, growth delay Intellectual impairment Water, BM if it is in the H2O and mom has adequate Iodine Water, salt, oil injection, BM supplement mother and infant
Zinc Growth retardation Immune deficiency, skin disorders, cognitive function Animal flesh, oysters, shellfish, BM Flour, maize, rehydration salts, sprinkles, BM -OK
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Development
AGE MILESTONES
6 MONTHS Watches faces, objects, smiles responsively, reaches / grasps objects both hands, turns to name / sounds, babbling, plays with fingers hands to mouth , sits, decreased head lag
12 MONTHS Simple gestures shake head no, waves bye, says mama, dada, pulls to stand crawls cruises, follows simple commands
2 YEARS Says words (50 are understandable), 2-4 words in a sentence, kicks a ball, walks without help, gets excited, points to things when named, follows simple instructions
3 YEARS Copies others, converses in 2-3 phrases/sentences, climbs stairs and other things, plays make-believe, shows affection without prompting, 75 of speech understandable
4 YEARS Hops and stands on 1 foot for 2 seconds, prefers to play with other children rather than alone, plays cooperatively, tells stories, draws a person with 2-4 body parts, 100 of speech understandable
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Anemia
AGE, person, location Hb (hemoglobin) Hct (hematocrit)
Children (0.5 5 years) lt 11 lt 33
Children (5-12 years) lt 11.5 lt 34.5
Children (12-15 years) lt 12 lt 36
Non-pregnant women (gt 15 years, sea level) lt 12 lt 36
Non-pregnant women (gt 15 years, _at_ altitude, e.g. Quito 7800 ft / 2800 m) lt 12.3 lt 37
Screening all children 1-6 years old, girls /
women gt12 years old Treatment 3-5 mg elemental
iron/kg/day with juice / water between meals
(not with milk), 3 months build iron stores
without ongoing losses, diarrhea / blood in
stool / parasites, menses, chronic undernourished
due to lack of appropriate foods)
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Abdominal Pain DiarrheaIntestinal Parasites

• Inter related and overlapping ? diarrhea and
  intestinal parasites can be the cause of pain
• Abdominal pain has a broader, multi-organ
  differential
• Diarrhea can be acute or chronic and has a broad
  etiologic differential
• Intestinal parasitic infections tend to be
  chronic with non-specific symptoms

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Abdominal Pain

• Careful history and physical exam associated
  symptoms
• Acute - look for a surgical condition
• Chronic consider peptic disorders, reflux,
  esophagitis, gastritis, ulcers, H. pylori,
  parasites, recurrent abdominal pain, UTI,
  abdominal migraines, inflammatory bowel disease
• Red Flag Symptoms weight loss, bilious emesis,
  intermittent diarrhea constipation, bloody
  diarrhea, fever, arthritis/arthalgias,
  hepatosplenomegaly, dysphagia, respiratory
  symptoms

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Diarrhea

• Acute diarrhea watery (volume), viruses ?
  rotavirus, adenovirus, enteroviruses, food
  intolerance if lt 24 hours, less commonly
  Salmonella, E. coli, Shigella, Cryptosporidium,
  Giardia, Campylobacter
• Chronic diarrhea (gt14 days) acute
  malnutrition (Zn or Vit. A), or recurrent
  episodes, bacteria E.coli (EAEC, EPEC),
  Shigella, Salmonella, Cryptosporidium,
  Cyclospora, Giardia alternating with
  constipation /- abdominal pain think parasites
• Acute bloody diarrhea small frequent bloody
  stools, pain, tenesmus Shigella, Campylobacter,
  Entamoeba histolytica, antibiotics or
  hospitalization consider Clostridium difficile,
• Diagnosis labs only for chronic diarrhea, or
  persistent bloody d.
• Therapy avoid antibiotics unless febrile,
  anti-diarrheal meds are ineffective / not advised
  in children, ORT, nutrition, education

Keusch GT et al. Diarrh. Diseases. C 19 Dis
Control Priorities in Dev Countries
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Parasites
Parasite Importance Diagnosis Therapy
Giardia , water sources, persistent diarrhea, FTT Copro exam of stool Empiric Albendazole 10-15mg/kg QD x 5 da Metronidazole 15-30mg/kg Q8h x 5 da Furazolidone, Nitazoxanide
Amebiasis Non-specific GI, Colitis, Ameboma, liver abscess EIA stool, EIA blood, colonoscopy Metronidazole 30-50mg/kg Q8h for 7-10 days Luminal agent - paromomycin
Tapeworms (T. Solium/Saginata) Asymptomatic, anorexia, abd. pain, FTT, Neurocysticersosis Seen in stool, Praziquantal 5-10mg/kg x 1
Hookworms-N. americanus, Ancylstoma skin dermatitis / itch, non-specific GI, Fe, nutritional def. Albendazole 400mg PO x 1 Mebendazole 100mg BID x 3 da
Pinworms Perianal itching, excoriation, rash Exam, Tape test, stool, Albendazole 100mg x 1 or 400mg PO x 1 if gt 2 yrs.
Ascaris Abd. pain, nausea, diarrhea, GI obstruction, Loefflers Syn. Copro exam Albendazole 200mg x 1 or 400mg PO x 1 if gt 2 yrs.
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Important Arthropod-borne Illness

• Malaria - 2009

• Dengue - 2010

WHO Reports
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Comparison

• Malaria

• Dengue

• Children 3-36 months, pregnancy
• Incubation 12-35 days
• Uncomplicated ? fever non-specific sxs
• Complicated ? cerebral, hypoglycemia, acidosis ,
  renal / liver failure, anemia, ARDS, CV collapse
• Recrudescence, relapse, repeat
• Prophylaxis
• Dx clinical, Giemsa stained smears, parasite
  density
• Rx various drugs ? specific types, Plasmodium
  (4) falciparum, vivax, ovale, malariae

• 50-100 million infections / yr
• Incubation 3-14 days (4-7)
• Asymptomatic initial episodes, mild febrile
  illness
• Dengue Fever fever -gt 41o , bone,
  headache,hematologic abnormalities, hyponatremia
• Dengue Hemorrhagic Fever / Shock biphasic fever,
  thrombocytopenia, ? Hct, low albumin Na, DIC,
  acidosis, CV collapse
• Severe disease prior infection(s)
• Mosquito protection!
• Dx clinical syndrome / endemic
• Rx supportive!!
• Serotypes DenV1-4

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Antimalarial Drugs
Drug Uncomplicated Complicated Prophylaxis Cost Available in U.S.
Chlorquine (lt 1)
Amodiaquine (-)
Quinine
Quinidine gt10
Mefloquine
Sulfadoxine- pyrimethamine
Atovaquone
Artemethr- lumefantrine
Clindamycin
Tetra Doxycyc
Primaquine hypnozoites ?prevent relapse
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Tuberculosis

• Clinical TB Disease 1o pulmonary, LN,
  other organs Cough, fever, weight loss, night
  sweats, malaise, hemoptysis
• Latent TB InfectionLTBI Rarely addressed
  TST, CXR, No Sx
• BCG (Bacillus of Calmette-Guérin) Scars -
  deltoid Protection meningitis, miliary
  TB Effect on TST cutoffs, lt 5yrs, gt15 mm
• Multi-drug Resistant TB MDR-TB Poor-complian
  ce, mutations Co-infection with HIV
  TB Inadequate infrastructure / Public Health
  / DOT

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Tuberculosis

• Dx clinical, CXR, smears, AFB,
  uncommonly culture, DNA
• Rx Isoniazid Rifampin (rifamycins) Pyazinamide
  Ethambutol 2o line agents Directly Observed
  Therapy (DOT) Public Health

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BCG Vaccination PolicyA Universal BCG
vaccination B BCG in the past, C never gave
BCG
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BCG Scars
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TST Reactions