Module 2.3 (Common childhood disorders, GI conditions, enuresis, atopy management)

Question 1

What are some neonatal conditions?

Answer 1

• neonatal respiratory distress syndrome
• patent ductus arteriosus

Question 2

What is neonatal respiratory distress syndrome (RDS)?

What are the symptoms?

What are some risk factors?

Answer 2

• respiratory failure in pre-term neonates caused by pulmonary surfactant deficiency- hyaline membrane disease
• incidence is 71%- gradually develops over 1st 6 hours after birth, progresses over first 48-72 hours–> recovery
• pulmonary surfactant prevents alveolar collapse and pulmonary oedema, not present in sufficient amounts before 34 weeks
• S & S= grunting noises, nasal flaring, bilateral poor air entry, cyanosis (blue skin)
• risk factors= male, diabetic mother, elective caesarian

Question 3

How is neonatal respiratory distress syndrome managed?

Answer 3

• can give AB emperically until diagnosis confirmed is case of aspiration pneumonia or sepsis
• For prevention:
  
  • maternal administration of glucocorticosteroids during pre-term labour:
    
    • betamethasone injection 11.4mg IM single dose: second dose after 24 hours, unless delivery occurs
    • dexamethasone IM 6mg q12h for 4 doses if delivery hasn’t occured
    • accelerates foetal lung maturation and reduces neonatal death, respiratory distress syndrome (RDS) and cerebroventricular haemorrhage
• For treatment:
  
  • Intra- tracheal exogenous surfactant: beractant, poractant alpha

Question 4

What is patent ductus arteriosus PDA?

Answer 4

• in a term neonate, the DA usually closes within the first few days of life
  
  • in utero- babies do not require oxygenation of blood from lungs
  • when it fails to close- PDA
  • allows blood to flow between the aorta and the pulmonary artery–> increase flow in the lung circulation
  • if PDA is large the pressure in the lungs may be increased- heart failure
  • small PDA- risk of infective endocarditis

Question 5

How is patent ductus arteriosis- PDA treated?

Answer 5

• IV indometacin
• IV ibuprofen (NA)
• catheter based procedure
  
  • neonatal period, only if they have to
• surgery

Question 6

What are some other neonatal conditions?

Answer 6

• ASD atrial septal defect
  
  • “hole in the heart”
  • all babies born with opening between atria and after birth it usually closes over a few weeks/ month. if septal tissue doesnt close= ASD (congenital heart defect)
• Patent foreman ovale (PFO)
  
  • “hole in the heart”
  • PFOs can only occur after birth when the formean ovale fails to close
  • foreman ovale is a hole in the wall between the left and right atria of every human foetus
  • increased risk of stroke if clot passes through

Question 7

What is gastroenteritis?

Answer 7

• vomitting and/or diarrhoea
• can be viral, bacterial or protozoal
• usually self limiting but can be a sign of something more serious
• need to monitor for dehydration

Question 8

What are signs of dehydration in gastroenteritis?

Answer 8

• no or mild dehydration
  
  • no physical signs or thirst, dry mucous membranes (dry mouth), reduced urine output- dark in colour
• moderate dehydration
  
  • dry mucous membranes, reduced urine output, tachycardia, sunken eyes, minimal or no tears, diminished skin turgor, altered neurological status (irritability, drowsiness)
• severe dehydration
  
  • increasingly marked signs from the above group, cool, mottles, pale peripheries, capillary refill time>2 secs, anuria, hypotension, circulatory collapse

Question 9

How is gastroenteritis managed?

Answer 9

• encourage parents to find ways to get kids to drink water
  
  • e.g. cup, icypole, syringe, aiming for small amounts of fluid often
• use water or oral rehydration solutions (ORS) eg. gastrolyte, hydralye, pedialyte 10-20mL/kg/hr of fluid
• give frequent small amounts of ORS
• significant ongoing GI losses: consider NGT rehydration
• avoid soft drink and homemade ORS
• continue breastfeeding and can also give water/ ORS if tolerated
• replace formula with water or ORS (do not dilute formula)
• eat as tolerated once rehydrated (avoid sweet/ fatty foods)
• may develop temporary lactose intolerance

Question 10

What is the main cause of vomitting?

Answer 10

• gastroenteritis (most common) but not always gastroenteritis
• stomach flu or intestinal infxn
• but can also be GI, neurological, endocrine

Question 11

What do we need to look out for in vomitting?

Answer 11

• nature of vomit. (blood, faecal odour, bilious)
• frequency of vomiting & progression & force of vomitting
  
  • relationship to feeding or position and duration of vomiting illness
• bowel actions, abdominal pain or distension
• infectious contacts, febrile, symptoms of UTI or URTI?
• hx of trauma or on medications that upset stomach?
• possibility of accidental/ deliberate poisoning?
• refer to Dr is any red flag symptoms
• <6 months refer to Dr

Question 12

What are some differential diagnosis for vomitting?

Answer 12

Question 13

What medications are used in vomitting and diarrhoea?

Answer 13

• generally not recommended
• ondansetron (dose 0.1 to 0.15mg/kg sublingual or IV) should not be routinely used, but can be considered in: n gastroenteritis: to allow successful rehydration n cyclical vomiting syndrome
• AVOID- metocloperamide and prochlorperazine
  
  • significant risk of serious EPSE and dystonic reactions, cross BBB
• AVOID- anti-diarrhoeal medication
  
  • loperamide- paralytic ileus, death, has been reported
  • diphenoxylate-CNS depression, resp depression and death

Question 14

How is post-op & chemo-induced nausea & vomiting managed?

Answer 14

• antiemetics may be used

Question 15

What is GOR?

Answer 15

• gastro-oesophageal reflux
• the passage of gastric contents into the oesophagus
• clinical presentation of vomiting or regurgiation is very common in infants and in the majority of cases self-resolving and does not need treatment
• peaks up to about 4 months, 6-7 months symptoms decrease, at 12 months only 5% symptomatic
• Usually resolves spontaneously:
  
  • Lower oesophageal sphincter becomes more functional
  • Baby spending less time lying down
• GORD is GOR leading to complications

Question 16

What are the symptoms of GORD?

Answer 16

• Vomiting with pronounced irritability with arching
• Refusal to feed
• Weight loss or crossing growth percentiles
• Haematemesis n Chronic cough, wheez
• Apnoea’s
• Disrupted sleep/difficult to settle

Question 17

How is GORD managed?

Answer 17

• lifestyle factors
  
  • positioning
    
    • tummy time (observed), raised head of bed
  • thickeners
  • smaller, more frequent feeds (not <3 hourly)
  • slow teat, keep bottle horizontal (avoid aerophagia)
  • do NOT change BF to formula or change formula without advice
  • avoid gastric irritants if possible
  • avoid exposure to tobacco smoke

Question 18

What medications are used to manage GORD?

Answer 18

• omeprazole
• PPIs: Disperse in 2-3mL water (in oral syringe). Don’t crush pellets. Once dispersed, consume in 30 minutes
  
  • Can also make extemp oral suspension
• PPIs effectively reduce gastric acid
  
  • Evidence suggests not effective in relieving the symptoms of infant GORD traditionally attributed to acid reflux, such as irritability, crying and fussing
  • Avoid regular Mylanta (Al and Mg)
• occasional doses of gaviscon can be given
  
  • mg2+–> constipation & potential effects on brain development

Question 19

What is colic?

Answer 19

• unsettled or crying babies
• crying is normal physciological behaviour in young infants
  
  • At 6 - 8 weeks age, a baby cries on average 2 – 3h per 24 hours
  • Excessive crying is defined as crying >3 hours/day for >3 days/week
  • Infants with colic are well and thriving and no medical issues
  • The parents are often distressed, exhausted, and confused, having received conflicting advice
• usually worse in the afternoon/ evening, may last several hours
  
  • infant draws up legs as if in pain
• usually improves by 3-4 months of age
• no evidence for benefit of medication
  
  • No evidence of benefit for simethicone or “gripe water”
  • Anticholinergic medication may cause serious AE’s (apnoea, seizures)
  • antihistamines – increase SIDS risk
  • Avoid herbal tea, alcohol etc

Question 20

What are some other causes of crying in babies?

Answer 20

• tired
  
  • Sleep per 24 hours: at birth: 16 hours, at 2 - 3 months: 15 hours
  • a 6 week-old baby usually tired after being awake for 1.5 hours
  • a 3 month-old baby usually tired after being awake for 2 hours
• hungry
  
  • n Esp if baby feeding every 3 hours, poor weight gain, poor milk supply
• differential diagnosis
  
  • GORD, cow milk/soy protein allergy, lactose intolerance
  • If acute onset: UTI, OM, hair tourniquet of digits, corneal abrasion, incarcerated inguinal hernia
• consider post-natal depression/anxiety risk in mother (Edinburgh Depression Scale)

Question 21

What is enuresis?

Answer 21

• lack of bladder control overnight in a person who has reached an age at which control is expected (usually 5 – 6 years)
  
  • Common childhood problem
  • Monosymptomatic nocturnal enuresis refers to children with normal daytime voiding patterns and night time wetting only
  • Non-monosymptomatic enuresis refers to enuresis in children with daytime wetting and / or additional lower urinary tract symptoms

Question 22

Is enuresis primary or secondary?

Answer 22

• it can be both
• primary- child has never been dry at night
• secondary- proviously established continence- they’ve had it before

Question 23

What are some causes of enuresis?

Answer 23

• genetic, bladder capacity, deep sleeper
• constipation, excess urine production at night

Question 24

How is nocturnal enuresis managed?

Answer 24

• Treatment
• age >5.5years or older
  
  • Different approach if also daytime sx
• Alarm therapy most effective (PCH Clinic referral)
  
  • Pad and bell
  • May take 6-8 weeks to work
• Education: fluid intake, toileting patterns, reward system
  
  • Strongly discourage punishment
• medication- desmopressin
• Vasopressin analogue- Synthetic ADH
  
  • Reduces the volume of urine in the bladder
  • Use when alarm has failed or is not appropriate
  • Treat for 1-3 months and then withdraw to assess for relapse
  • Given as oral or S/L at bedtime (intranasal à ↑risk hyponatremia)
    
    • Initially 200mcg tab (120mcg Melt SL) at bedtime (>6yrs)
    • If not completely dry after 1-2 weeks consider ↑ dose
  • AE: headache, nausea, dizziness, hyponatremia
  • Must limit Fluid intake from 1 hour before dose until 8 hours afterwards
  • Rare: water intoxication (↓Na and seizures)– if excessive fluid intake

Question 25

How is enuresis managed if associated with daytime symptoms?

Answer 25

* Nocturnal enuresis associated with daytime symptoms can be managed with anticholinergics in combination with desmopressin * oxybutynin (also used for overactive bladder and bladder spasm) * Caution anticholinergic AE’s (flushing common in children) * TCAs * Imipramine was most commonly used * AE: behavioural disturbances can occur and relapse is common after withdrawal * Toxic in overdose * no longer recommended

Question 26

What is atopy?

Answer 26

* develop IgE antibodies to commonly inhaled or ingested allergens * an eexaggerated IgE-mediated immune response; all atopic disorders are type I hypersensitivity disorders (allergies) * Atopic disorders commonly affect **nose, eyes, skin and lung**s * **Eczema/Dermatitis, Asthma, allergic rhinitis and conjunctivitis** * management * Allergen identification and avoidance * Symptom management

Question 27

What is eczema? WHat is the diagnostic criteria?

Answer 27

* dry itchy chronic inflammatory skin condition, which typically begins in early childhood * affects approximately 30% of children * usually starts at less than 12 months of age * it follows a remitting and relapsing course * tends to resolve in most children by 5 years * diagnostic criteria * Must have itchy skin plus three or more of the following: * Onset usually \< 2 years * History of or current flexural involvement * History of dry skin within the past year * History of atopic disease in patient or 1st degree relative * in babies eczema can affect everywhere including the scalp, ears and face * in older children it tends to affect the elbows, knees and wrist

Question 28

How is eczema managed?

Answer 28

* everyday treatment * avoiding environmental aggravators; * Heat (short, lukewarm baths, light loose clothes to bed) * Prickly/rough material (cotton, cotton/polyester – cut off labels) * AVOID SOAP and caution other irritants (eg chlorine, sand) * Cut nails short, mittens, splinting at night if severe * Daily bathing in lukewarm water with dispersible bath oil in bath water e.g. QV® bath oil, Dermaveen® bath oil, Hamilton® dry skin bath oil * Max of 5 minutes in bath * Soap and shampoo substitutes * QV® gentle wash, Dermeze® soap free wash, Cetaphil® body wash * Moisturiser: The drier the skin the thicker the emollient needs to be (e.g. ointment or thick cream) and the more frequent the application * Application after bath and at least twice daily * Ointments e.g. Dermeze® ointment, QV® intensive body moisturiser, QV® kids balm * Creams e.g. Dermeze thick cream, Cetaphil® cream, QV®cream

Question 29

What are some different types of emollients and their properties?

Answer 29

Question 30

What's good about ointments?

Answer 30

* increased **moisture** & decreased **stinging**

Question 31

How are flare ups managed?

Answer 31

* topical corticosteroids * Use on all areas of inflammation until it’s settled * Pre-empt and address parental concerns about potential AE * Atrophy uncommon unless inappropriately strong preparations are used on face, axillae, groin * Systemic absorption: Adrenal suppression is uncommon. Chronic illnesses (eg poorly controlled atopic dermatitis) can cause growth delay * Step down when the symptoms are controlled * Use an ointment base not a cream ↑moisturising and ↓stinging * Cream on weeping rash * Lotions/hydrogels on hairy areas * Once-daily application is usually sufficient * Liberal application is often required to all areas of inflammation * Select suitable potency for the area being treated

Question 32

What is recommended depending on severity of eczema?

Answer 32

Question 33

How much cream does 1 FTU cover?

Answer 33

* 1 FTU= 2 flat adult hands with finger tips together

Question 34

What are the guidelines for FTUs depending on age of patient?

Answer 34

Question 35

What is a non steroidal topical cream for eczema management?

Answer 35

* pimecrolimus 1% cream is an immunosuppressant with equivalent strength to mild topical corticosteroids * inhibits calcineurin thus blocking T cell proliferation and preventing release of inflammatory cytokines * low potency, so is not adequate for acute, severe flares n Can be useful on sensitive areas (eg face/eyelids, axillae, groin) as a maintenance preparation or to abort early flares * Initial concerns about potential long-term carcinogenic effects of pimecrolimus have not been substantiated * Due to concerns about possible ↑ AE’s (URTI’s, OM, diarrhoea, asthma, irritability) not approved for use in children \<2 years in the USA or the UK * pimecrolimus 1% (adult or child older than 3 months) topically once or twice daily

Question 36

What are wet dressings?

Answer 36

* cool the skin and help reduce the itch: helpful if child hot and itchy or walking at night with itch * Cool compresses are used as wet dressings to the face * Help with penetration of topical corticosteroids for severe inflammation or when the skin is thickened and lichenified

Question 37

How is a wet dressing applied?

Answer 37

* take a bath or shower and lightly pat dry skin * apply topical corticosteroid to affected skin * cover treated skin with damp (wrung-out) wet dressings, soak dressings in water that is a comfotable temperature * for babies, use a jumpsuit for the dressings * for older children, use pyjamas, elasticated tubular bandages, towels, sheets, cotton socks, or cotton gloves * wrap in a towel or wear dry clothes on top, to keep warm and ensure the damp layer is in close contact with the skin * remove the wet dressings after 15-60 minutes * dry the skin, then apply an emollient

Question 38

How is infected eczema managed?

Answer 38

* Dilute bleach baths (usually prescribed twice a week for three months): * Anti-infective treatment shown to n ↓ incidence of recurrent Staphylococcal aureus superinfection * Improves the condition of the skin * Infected eczema * Flucloxacillin or Cephalexin orally for 10 days * Infected eczema with herpetic lesions * Aciclovir orally for 5-7days * Localised staphylococcal skin infections * Mupirocin 2% ointment/cream to crusted areas bd for 7 days * If the child has very severe infected eczema admit to hospital for intravenous administration

Question 39

NRD - neonatal respiratory distress summary

Answer 39

* Lack of pulmonary surfactant in pre-term neonates à resp failure * Prevention * IM betamethasone to mother in pre-term labour to speed up foetal lung maturation * Treatment n Beractant or poractant (exogenous surfactant)

Question 40

PDA Patent Ductus Arteriosis summary

Answer 40

* When ductus arteriosis fails to close – can à HF or infective endocarditis * Term neonate with no symptoms * Wait until older for catheter-based procedure (or neonatal surgery if sx) * Pre-term neonate * IV NSAID * If still symptomatic à neonatal surgery

Question 41

Gastroenteritis summary

Answer 41

* Gastroenteritis * Vomiting +/- diarrhoea * 70% viral, 20% bacterial and 10% protozoal (know these bugs!) * Red flags * Significant abdominal pain, co-morbidities, \< 6 months age, high fever, prolonged symptoms, or signs suggesting a surgical cause * Watch for dehydration (know the symptoms!) * Oral rehydration * Water, ORS, breast milk – small amounts, frequently * AVOID soft drink, diluted formula, sweet/fatty foods * Differential diagnosis * GORD, intussusception, diabetic ketoacidosis, appendicitis, cyclical vomiting, UTI, URTI, GIT obstruction, poisoning, adrenal crisis, CNS infection, head injury * Medications * Once-off ondansetron * AVOID – metoclopramide, prochlorperazine, loperamide, diphenoxylate * CINV – dexamethasone, aprepitant, metoclopramide may be used

Question 42

GORD summary

Answer 42

* GOR very common * ↓LOS tone and positional – usually resolves spontaneously with time * GORà complications = GORD * Vomiting with irritability, poor feeding, weight loss, cough, apnoea, unsettled * Treatment * Lifestyle * Position, ?thickeners, smaller, frequent feeds, avoid aerophagia and gastric irritants * Medication * PPI’s (omeprazole) –disperse in water or extemp oral iquid * ↓ acid but unclear if ↓sx * Differential diagnosis * Colic * Understand feed/wake cycles of neonate/infant * Risk of post-natal depression and anxiety in parents

Question 43

Enuresis summary

Answer 43

* Nocturnal enuresis common childhood problem * Most grow out of it with time * Genetic, bladder capacity, deep sleeper * Manage constipation if present * Primary vs secondary vs daytime enuresis * Treatment * Age \>5.5yrs (usually older) * Alarm therapy with education is 1st line * Medication * Desmopression – if alarm has failed or not appropriate * Tablets or sublingual * Must limit Fluid intake from 1 hour before dose until 8 hours afterwards (↓Na) * Oxybutynin for daytime sx (overactive bladder/spasms)

Question 44

Atopy summary

Answer 44

* IgE mediated immune response (allergy) * Eczema/asthma/allergic rhinitis/conjunctivitis * Eczema * Dry itchy chronic inflammatory skin condition, which typically begins in early childhood * Genetic component * In babies eczema can affect everywhere including the scalp, ears and face * In older children it tends to affect the elbows, knees and wrist

Question 45

Eczema management summary

Answer 45

* Soap substitutes, emollients and allergen and irritant avoidance * Know which soap substitutes and emollients to recommend and when * topical corticosteroids * Pre-empt and address parental concerns about potential AE * Atrophy and adrenal suppression NOT common vs risks of poorly tx disease * Know potencies and which one to apply where and how much to apply * Pimecrolimus * Low potency, ok on sensitive areas. ?possible AE’s * Severe dermatitis * Wet dressings, phototherapy, oral immunosuppressants, sedating antihistamine * Infected dermatitis * Dilute bleach baths, antibiotics, antivirals, mupirocin