Transcript medley of updates - Paediatric Society

PAEDIATRIC SOCIETY
Dr Sridevi Arikala
Updates
 ALTE- Acute Life threatening Event
 SIDS- Sudden infant death syndrome.
 ADHD- Attention deficit hyperative disorder
 Autism
 Cows milk allergy.
Acute Life Threatening Event
An episode in an infant that is frightening to the
observor
 Apnoea 20 seconds or longer
 Colour change – cyanosis or pallor
 Marked change in muscle tone
 Choking or gagging
Diagnosis based on symptomatology rather than
pathophysiology
Differential diagnosis
Central
Obstructive
 Seizure
 GE reflux
 Breath holding spell
 Acute abdomen
 Metabolic
 LRTI
 Cardiovascular
 Foreign body
 Infection
 NAI
 Drugs
Paediatrics in Review June 2012
 50% - Cause not known
 GE reflux ; Seizure and LRTI- 50%
Recently recognised risk factors
 Post conceptional age of < 48 weeks in preterm babies
 Post natal age of < 1 month
 First 2 hours after birth-Most cases are obstructed
airway; frequent checks by health personnel.
Investigations- Dutch Pediatric
Association.
 CBC
 C-reactive protein
 Blood glucose
 Arterial blood gas
 Urine analysis
 ECG
 RSV/Bordetella
What this update adds
 EEG
Diffiult to obtain in emergency setting
Sensitivity of EEG 15 % in diagnosis( Bonkowsky et al2008)
Patients with epilepsy will return with a second episode
EEG reserved for children with recurrent ALTE
What this update adds
 CT scan reserved for children with suspected child




abuse.
Multiple history taking from caregivers to note
discrepancies.
Fundus exmination and Skeletal surveys to follow.
Serum Metabolic Studies – Organic acidemias ; Urea
cycle disorders ; fatty acid oxidation defects and
mitochondrial disorders cause 2-5% of ALTE
Serum electrolytes – Na;K; Ca; Mg; Ammomia; lactate
pyruvate
What this update adds
 Urine toxicology- Usually cold and cough mixtures.
 Gastroesophageal reflux- Ph probe testing showing
reflux should coincide with respiratory symptoms
Reserved for infants with frequent GE reflux ; ALTE
preceded by feeding; milk found in mouth and nose
 Hospital admission –Recommend 24 hours of
observation .
 Resources for infant basic life support Courses.
Paediatrics in Review June 2012
American academy of Paediatrics SIDS Task force
recommendations.
Definition Of SIDS
 Sudden unexplained death before 1 year of age.
 Previously healthy infant.
 Cause of death unexplained despite
case investigation.
complete autopsy.
death scene investigation.
review of clinical history.
Risk reduction factors for SIDS
 Back to sleep for every sleep.
 Use a firm sleep surface.
 Keep soft objects and bedding out of the crib.
 Avoid tobacco smoke.
 Room sharing without bedsharing.
 Pacifier at nap time and bed time.
 Avoid overheating.
 Do not use cardiorespiratory monitors as strategy to
reduce risk of SIDS.
What this update adds
 Reduction in SIDS cases.
 Rise in cases of ASSB- Accidental suffocation and
strangulation in bed.
What this update adds.
Bed sharing particularly dangerous
 Infant < 2-3 months of age
 One or both parents are smokers.
 Infant is placed on sofa; arm chairs or waterbeds.
 Multiple bed sharers.
 Person bed sharing has consumed alcohol;
medications or illicit drugs.
What this update adds.
 Breast feeding- protective effect on SIDS.
Decreased infectious diseases.
Breast fed infants more easily aroused than formula
fed infants.
 Pacifier- protective effect on SIDS
However to be introduced 2 to 4 weeks of age.
What this update adds
 Room ventilation and fans- Currently no
recommendation for or against fan use as SIDS risk
reduction strategy.
 Swaddling- No recommendation for or against
swaddling as risk reduction strategy.
Swaddle should not be tight so as to effect respiration
or exacerbate hip dysplasia.
Not loose as to create head covering; suffocation or
strangulation.
Update
Diagnostic and
statistical manual of
mental disorders.
Attention deficit Hyperactive
disorder
 Update based only on Diagnostic Criteria.
 Previously Diagnostic and Statistical Manual of
mental disorders IV was used.
 DSM-5 published in May 2013
 Diagnosis still based on Inattention- 6/9 criteria
and/or 6/9 of hyperactive/impulsivity criteria
What this Update adds
DSM IV
DSM V
 Grouped under Disruptive
 Grouped under
 Diagnostic criteria
 Illustrated examples of behavior
behavioural disorder
predominantly for children
Easily distracted- extraneous
objects
Forgetful of dialy activitiesRunning errands
Child runs about
Neurodevelopmental disorder
for adults/children
Adults- Unrelated
thoughts
Forgetful of daily activitiesPaying bills/keeping appointment
Adult- Feeling restless
DSM IV
DSM V
 6/9 of inattentive and or 6/9
 Over 17 years 5 criteria are
of hyperactive/impulsive
criteria
 Symptoms should have been
present before 7 years
 Symptoms should cause
significant impairment in
social; academic or
occupational functioning.
sufficient
 Symptoms should have been
present before 12 years.
 Symptmoms should intefere
with or reduce quality of life
in social academic or
occupational functioning.
DSM IV
DSM V
 Exclusion criteria for ADHD
 Exclusion criteria for ADHD
Pervasive devt disorder
Schizophrenia
Other psychotic disorder
Schizophrenia
Other psychotic disorder
 Subtype Classification
 Subtype Classification
Combined Type.
Predominantly inattentive
Predominantly hyperactive
 Severity
Combined presentation
Predominantly inattentive
hyperactive presentation
 Mild ; moderate; severe
Update on Autism.
DSM-IV
DSM-V
Pervasive developmental
disorders
 Autism
 Aspergers syndrome
 PPD-NOS
 Retts syndrome
 Childhood disintegrative
disorder
Autism Spectrum disorder
Autism
Aspergers syndrome
PPD-NOS
Childhood disintegrative
disorder
Shift from categorical to
Dimensional
 Categorical subtypes- clinical diagnosis not reliable.
 Few differences between high functioning Autism
and Asperger’s
 One spectrum of autistic disorders defined purely by
behaviours
3 key domains become 2
DSM IV
DSM V
 3 criteria
 Social impairment and
communication
 Restricted and repititive
behaviour
Rationale for dyad
 Multiple criteria assess same symptom
 Deficits in communication and social behaviors are
inseparable.
 Delays in language are not unique nor universal in
ASD .
Social Impairment and
Communication
 Deficits in social-emotional reciprocity
 Deficits in nonverbal communicative behaviors
 Deficits in developing and maintaining
relationships, appropriate to developmental level.
All three need to be present- increase specificity.
Restricted/Repetitive behaviour
 Stereotyped or repetitive speech
 Excessive adherence to routines
 Highly restricted, fixated interests
 Hyper-or hypo-reactivity to sensory input
Two RRB instead of one- improves specificity.
ASD –DSM5 Specifiers and
Modifiers
 With the new criteria, if the child meets for ASD he /
she will receive a diagnosis with the etiology as a
specifier
–ASD with Rett Syndrome
–ASD with Fragile X
 OR with a modifier indicating another important
factor
–ASD with tonic-clonic seizures
–ASD with intellectual disabilities
Levels of severity DSM V
 Level One - Requiring support.
 Level Two-
Requires substantial support
 Level Three- Requires very substantial support.
Cows milk Allergy – ESPGHAN
guidelines 2012
Immediate Reaction
Late Reactions
 Dermatological:
Angio-oedema, urticaria, pruritis,
erythema.
 Respiratory:
Rhinitis, chronic cough/ wheeze
(unrelated to infection), acute
laryngoedema.
 Systemic:
Anaphylaxis.
 Gastrointestinal:
Quick onset vomiting and
diarrhea (within 2 hours)
 Dermatological:
Atopic eczema.
 Gastrointestinal:
Reflux,
diarrhoea
constipation,
blood in stools (colitis)
iron deficiency anaemia
growth faltering
Investigations for CMPA
Skin tests and positive IgE
 Indicate sensitisation and may not mean allergy.
 Quantification of these tests useful in prognosis
 Negative in gastrointestinal reactions.
Elimination diet and Oral challenge- Gold standard for
diagnosis
Breast Fed Infants
 Continue breast feeding
 Elimination of CMP from mother’s diet
 No improvement- Diagnosis unlikely
 Improvement- Oral challenge and if symptoms recur
elimination diet for the mother
weaning onto EHF
Formula fed infants- Elimination
diet
 Extensively hydrolysed formula
First choice for most infants..
 Aminoacid formula
If EHF does not work.
Costly.
 Soy based formula
> 6 months.
Taste better.
Less costly.
Risk of micronutreint deficiency
Formula fed infants- Severe
reactions
 Skin prick test positive or IgE positive
oral challenge not required.
 CMP protein free diet for one year.
 Reevalaution done after 1 year under controlled
circumstances
Neither clear nor severe Reactions
 Oral challenge for 2 weeks.
 If positive; elimination diet for 6 mon.
 Skin test negative or low titres of IgE antibody
reevalation after 6 months and can be done at home.
 Prognosis 50% tolerance by 1 year
75% tolerance by 3 years
90% tolerance by 6 years.