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UF Service Trips Common Clinical Issues in Children

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Title: UF Service Trips Common Clinical Issues in Children


1
UF Service TripsCommon Clinical Issuesin
Children
  • Rob Lawrence, MD
  • Pediatric Infectious Diseases

2
OutlineObjectives
  • An Approach to Diagnosis
  • Growth / Development / Anemia
  • Abdominal Pain / Diarrhea / Intestinal parasites
  • Dengue / Malaria
  • TB

3
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.

4
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)

14
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
15
Kwashiorkor
  • Growth Failure
  • Wasting muscles
  • Edema abdomen, scrotum, feet
  • Hair changes
  • Mental changes / activity
  • Dermatosis
  • Appetite diminished
  • Anemia
  • Fatty lliver

16
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
17
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
18
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
19
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
20
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)
21
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

22
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

23
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
24
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.
25
Important Arthropod-borne Illness
  • Malaria - 2009
  • Dengue - 2010

WHO Reports
26
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

27
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
28
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

29
Tuberculosis
  • Dx clinical, CXR, smears, AFB,
    uncommonly culture, DNA
  • Rx Isoniazid Rifampin (rifamycins) Pyazinamide
    Ethambutol 2o line agents Directly Observed
    Therapy (DOT) Public Health

30
BCG Vaccination PolicyA Universal BCG
vaccination B BCG in the past, C never gave
BCG
31
BCG Scars
32
TST Reactions
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