General Measures For Good Oral Hygiene

  1. Select the right quality of tooth brush which should be short, soft and have uniformly trimmed bristles
  2. Brush teeth at least twice a day for 2-3 minutes particularly at night before going to sleep.
  3. Use right technique of teeth brushing
  4. Never use force while brushing
  5. Avoid too much sugar and aerated drinks
  6. Avoid eating in between meals, if can not be avoided rinse your mouth or preferably brush your teeth
  7. Ensure regular dental checkup at 6 monthly interval

Tooth brushing is extremely important for cleaning teeth, for massage of the surrounding gums and maintaining oral hygiene. Regular brushing keeps the tooth surface free of plaque, which is soft material that gets deposited on the tooth surface and is the cause of dental caries and periodontal problems

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Inflammatory Gingival Enlargements

The gingival enlargement can be acute which is very painful or they can be chronic which may be painless.

Salient features

  • Acute enlargements may be localised or generalised, very painful, deep red in colour, soft friable with shiny surface.
  • Chronic type may be localised or generalised, often painless and slowly progressive.

Treatment

Pharmacological

  1. Tab Ciprofloxacin 500 mg 2 times a day for 3-5 days
  2. Tab Nimesulide 100 mg 2 times a day for 3-5 days
  3. Rinsing with 0.2% Chlorhexidine twice daily

Refer to a periodontist for surgical management and drainage of pus

Patient education

  • Proper brushing twice daily with super soft tooth brush

References

  1. Ramford and Ash. Periodontology and Periodontics. In: Modern theory and practice. 1st Indian edition AITBS Publishers 1996, pp 145.
  2. Shafer, Hine, Levy. In: A textbook of oral pathology. 4th edition, Saunders, pp 782.

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Juvenile Periodontitis

Common in the age group of 13-25 years characterized by rapid destruction of periodontal tissues.

Salient features

  • Mobility in incisors and molars, spacing in upper incisors, distolabial migration of upper incisors, arc shaped bone loss extending from distal surface of second premolar to medial surface of second molar.

Treatment

Pharmacological

Cap Tetracycline 250 mg 4 times a day for 14 days

Surgical

Extraction of badly involved teeth. Refer the patient to periodontist for further periodontical management at the earliest

Patient education

  • Proper brushing twice daily with super soft tooth brush.

References

  1. Ramford and Ash. Peridontology and Periodontics. In: Modern theory and practice. 1st Indian edition AITBS Publishers 1996, pp 166.
  2. Carranza. In: Clinical Periodontology, 5th edition, Saunders, pp 299.

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Adult Type Peridontitis

Most common dental disease includes diseases of the gum.

Salient features

  • Swollen gums, bleeding from gums either spontaneously or on eating something hard, difficulty in chewing food, dull pain in the gums, pus discharge from gum on pressing, loosening of teeth, recession of gums.
  • There is slowly progressive destruction of periodontitis, periodontal attachment loss and presence of periodontal pocket.

Treatment

Nonpharmacological

Advise brushing twice daily once after breakfast and once after dinner with super soft tooth brush for atleast 3 minutes and refer to a dentist for oral prophylaxis by thorough scaling and root planing.

Pharmacological

Local Therapy

  1. Rinsing with 0.2% chlorhexidine twice daily
  2. Gel Metronidazole to be massaged on the gums twice daily
  3. Gel Chlorohexidine to be massaged on the gums twice daily

Systemic therapy

In adults Cap Tetracycline 250 mg 4 times a day for 5-7 days. In children very deep pockets: Combination of drugs i.e.,

  1. Cap Ciprofloxacin 500 mg twice daily for 5-7 days
  2. Tab Tinidazole 600 mg twice daily for 5-7 days

Recheck the depth of periodontol pockets, if it persist, refer to a periodontist for further management.

References

  1. Ramford and Ash. Peridontology and periodontitis. In: Modern therapy and practice. 1st Indian Edition, AITBS Publishers 1996, pp 163.
  2. Mitchell D A, Mitcchell L. In: Oxford handbook of clinical dentistry, 2nd edition reprint.1996, pp 212.

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Dental Caries

This is a microbial disease of hard tissues of teeth characterized by demineralization of inorganic and destruction of organic part of the tooth.

Salient features

  • Usually asymptomatic in early stages. Patient presents with tooth sensitivity and tooth ache

Treatment

Examine for stage of caries and treat accordingly.

Nonpharmacological

In non-cavitated lesion and low risk patient with good oral hygiene practices, no treatment is given. In cavitated lesion, restoration is done

Pharmacological

Where caries is likely to progress (in high risk patient) pit and fissure sealout

  1. Topical 2% Sodium fluoride
  2. 0.2% Chlorhexidine mouth wash twice a day

Assessment of response to therapy

  • For caries active patient – follow up visit every 3 months and to check the progression of white spot on the teeth.
  • For normal patients – follow up every 6 months to 1 year to check the development of the white spot/cavitation

Patient education/prevention

For caries active/high risk patient preferably

  • Diet control and avoidance of sugar containing food
  • Frequent ingestion of food containing sucrose should be substituted by sugar free foods
  • Oral hygiene: a) brushing of teeth twice a day b) flossing c) thorough rinsing after every meal
  • Fluoride application using Topical 2% Sodium fluoride (by dentist) 4 applications at weekly intervals at the age of 3, 7, 11 and 13 years.
    0.05% sodium fluoride daily rinse, (should not be swallowed)
    0.2% sodium fluoride supervised weekly rinse in school (age of children >7 years) only if these children have been identified as caries active patients

References

  1. Sturdevant CM. Roberson TM, Heymann HO, Sturdevant JR. In: The Art and Science of Operative Dentistry, 3rd edition, Mosby 1995, pp 100-120.
  2. Mitchell DA, Mitchel L. In: Oxford Handbook of Clinical Dentistry, 2nd edition, reprint 1996, pp 28.

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Lateral Peridontal Abscess

Salient features

  • Same as in acute periapical abscess often associated with bad taste. Tooth is usually mobile and tender on tooth percussion, with associated localized or diffuse swelling of the adjacent periodontium.
  • Vitality test usually positive if no associated pulpal problem.
  • Radiograph shows vertical or horizontal bone loss in relation to the tooth.

Treatment

Pharmacological

  1. Cap Amoxycillin 250-500 mg 3 times a day for 5 days
  2. Tab Metronidazole 400 mg 3 times a day for 5 days

For surgical treatment refer to a dentist for debridement of pocket and drainage of pus and irrigation with chlorhexidine. Spread of infection to be closely observed to prevent complications like Ludwig’s Angina.

Patient education

  • Maintenance of oral hygiene
  • No hot fomentation over the skin
  • Control of diabetes mellitus if present

References

  1. Ramford and Ash. Peridontology and Peridontics. In: Modern Therapy and Practice, 1st Indian edition AITBS Publishers 1996, pp 126
  2. Mitchell D A, Mitchell L. In: Oxford Handbook of Clinical Dentistry. 2nd edition, reprint 1996, pp 266.

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Dental Abscess

Patient presents with pain and swelling. The most common types of dental abscesses are periapical abscess and lateral periodontal abscess.

Periapical Abscess

Salient features

  • Severe throbbing pain, disturbed sleep, tooth is tender to touch, is extruded, mobile and may be associated with localized or diffuse swelling.

Immediate treatment

To give antibiotics as given below and refer to a dentist

Pharmacological

Cap Amoxycillin 250 -500 mg 3 times a day for 5 days
Or
Tab Ciprofloxacin 250-500 mg two times a day for 5 days

Surgical

Drainage of pus to relieve occlusion by entering the pulp chamber. If fluctuant swelling of soft tissue is present drain by incision. Extraction or root canal treatment should be done when acute symptoms subside. Spread of infection should be closely observed to prevent complications like Ludwig’s angina.

Patient education

  • Maintenance of oral hygiene
  • Control of diabetes mellitus, if present
  • No hot fomentation over the skin

References

  1. Kruger G O. In: Textbook of oral and maxillofacial surgery, 6th edition, C.V. Mosby 1984, pp 196.
  2. Grossman I I, Seymore O, Carlos D R. In: Endodontic Practice 2nd Indian Reprint 1991, pp 20

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Tooth Ache

The causes of toothache directly associated with tooth are caries, periodontal socket, abrasion, attrition, erosion and peridontitis. The indirect causes of toothache are maxillary sinusitis (recent bout of common cold), trigeminal neuralgia where pain is sudden, sharp, severe or short duration, like electric shock. Trigger zone may or may not be present.

Treatment

Pharmacological

  1. Cap Amoxycillin 250 – 500 mg 3 times a day for 5 days
    Or
    Tab Ciprofloxacin 250 – 500 mg 3 times a day for 5 days
  2. Tab Ibuprofen 400 mg 3 times a day for 3-5 days
    Or
    Tab Nimesulide 100 mg two times a day for 3-5 days
    For specific treatment refer to a dentist

Surgical

Removal of irritant (like high filling, high spot on crown or bridge). Excavation of caries and sedative dressing with clove oil. Anaesthetize the tooth and extirpate the pulp (if pulp is exposed). Assess the response by getting immediate radiographs, radiograph after 6 weeks to assess bone loss and root resorption, and clinical assessment of mobility of tooth after 6 weeks

Patient education

  • Maintenance of oral hygiene
  • Importance of tooth preservation should be explained
  • Pit and fissure sealing in paediatric patient
  • Not to bite anything hard from anterior teeth during fixation period

References

  1. Cohen S, Burns R C. Pathways of the Pulp. 5th Edition, Mosby 1991, 4, 27-28.
  2. Grossman L I, Seymour O, Carlos D R. Endodontic Practice. 2nd Indian Reprint, Lea & Febiger 1991, 4, 26.

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Tooth Avulsion

One of the commonest sequelae of facial trauma is tooth avulsion or exfoliation.

Salient features

  • History of fall, sports injury, assault or accident
  • Patient presents with a bleeding socket, clot in the socket and a raw wound.

Treatment (Immediately refer to a dentist)

  • Best result are observed if tooth is reimplanted within 5-10 minutes
  • Fixation of implanted tooth with periodontal wiring, arch bar wiring or composite resin; fixation period 6 to 8 weeks; root canal treatment done after replantation only (to avoid desiccation of periodontal ligament).

Interim storage

  • Best method is to place back the tooth in the socket immediately
  • Other storage mediums are saliva, milk (placed in ice since this minimizes the adverse effects on the periodontal ligament) and saline

Pharmacological

  1. Cap Amoxycillin 250-500 mg 3 times a day for 5 days
    Or
    Tab Ciprofloxacin 250-500 mg twice a day for 5 days
  2. Tab Ibuprofen 400 mg 3 times a day for 3-5 days
    Or
    Tab Nimesulide 100 mg 2 times a day for relief of pain

References

  1. Andreasen, J O, Andreasen, F M, Balkland L K, Flores, M T. In: Traumatic Dental Injuries – A Manual 1st edition Munksgaard 1999, pp 40.
  2. Cohen S, Burns R C. In: Pathways of the Pulp. 5th Edition, Mosby 1991, pp 479.

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Tuberculous Meningitis

Tuberculous meningitis is the inflammation of meninges due to lymphohematogenous spread of the primary infection of tuberculosis to the meninges, found in about 0.3% of untreated primary infection in
children. It is the most dangerous form of extra-pulmonary tuberculosis. 70% of the cases are found in children less than 5 years of age.

Salient features

  • The clinical progression of tubercular meningitis (TBM) may be rapid or gradual. The signs and symptoms progress slowly over several weeks and can be divided into three stages.
      • The 1st stage, which typically lasts 1-2 weeks, is characterized by non-specific symptoms, such as fever, headache, irritability, drowsiness and malaise. Focal neurologic signs are absent.
      • The 2nd stage usually begins more abruptly. The most common features are lethargy, neck-rigidity, seizures, positive Kerning or Brudzinski signs, hypertonia, vomiting, cranial nerve palsies and other focal neurologic signs.
      • The 3rd stage is marked by coma, hemiplegia or paraplegia, hypertension, decerebrate posturing, deterioration of vital signs, and eventually, death.
  • Complications: Survivors may have motor deficits, cranial nerve deficits, mental retardation, learning disabilities, seizures, hydrocephalus, blindness, deafness and diabetes insipidus.
  • The diagnosis is made by analysis of CSF on lumbar puncture, which shows lymphocytic leucocytosis with elevated protein and a low sugar (for details see table 1 in section on meningoencephalitis .

Demonstration of AFB in CSF confirms the diagnosis, but the yield is very poor.Culture of CSF shows growth of M. tuberculosis, takes too much time.Positive tuberculin skin test corroborates the diagnosis but may be negative in severely malnourished/disseminated disease. 20-50% of children have a normal chest radiograph others may show primary disease. CT Scan or MRI of brain may be normal during early stages of the disease. Later, it can show exudates in the basal cisterns of brain, periventricular ooze and hydrocephalus. Some may show tuberculomas even.

Treatment
Treatment consists of proper supportive care, including nonpharmacological treatment, specific antitubercular therapy, treatment of increased intracranial tension and, if required, surgical treatment.

Nonpharmacological

  1. Nutrition: after initial stabilization, nutritional rehabilitation should be done as given in section on protein energy malnutrition.
  2. Skin care and prevention of bedsores.
  3. Care of bowel and bladder.
  4. Physiotherapy and occupational therapy should be instituted early to prevent deformities and contractures..

Pharmacological

  1. Appropriate fluid therapy to correct dehydration due to frequent vomiting and decreased oral intake.
  2. Treatment of SIADH. Fluid restriction to 3/4or 2/3rd of maintenance. Treatment of raised intracranial tension
  3. Inj: Dexamethasone: 0.15 mg/kg IV 6 hourly for 2 weeks followed by
    Tab Prednisolone 1.5 mg/kg/day orally through feeding tube for 4 weeks. This should be tapered over another 2 weeks. A total of 6-8 weeks therapy with steroid is recommended.
  4. Mannitol (20% solution) 1.5 to 2 g/kg or 8-10 ml/kg over 30-60 minutes. Repeated every 6-8 hours for 7 days. Lower doses (0.25 g/kg/dose) can also be tried.
    Or
    Glycerol 1 ml/kg/dose every 6-8 hours, diluted in orange juice or water, given through feeding tube.
    Or
    Tab Acetazolamide 50 mg/kg/day, in 3 divided doses for 2-3 weeks.
  5. Anticonvulsant therapy – presence of seizures necessitates treatment with phenytoin or carbamazepine in appropriate doses.
  6. Specific antitubercular therapy – as given in management of tuberculosis (see section on tuberculosis).
  7. Surgical Treatment Ventriculoperitoneal Shunt (VP Shunt): All TBM show some degree of hydrocephalus by 4 weeks. Obstructive hydrocephalus should be shunted immediately. Non obstructive hydrocephalus with increased intracranial pressure as shown by ventricular tap or CT scan will also be benefited by VP shunt. An early shunt is preferable.

Follow up

  • Patient should be kept under follow up after discharge from the hospital and assessed for neurological deficit and features of increased intracranial pressure (ICP). One of the common cause of increased ICP is untreated hydrocephalus or blocked shunt.
  • Check compliance to drugs and ensure that occupational therapy/physiotherapy is being continued.
  • Assess physical, mental, visual and auditory handicap and take expert opinion for rehabilitation from other specialists.

Patient/parent education

  • Seriousness of disease must be explained.
  • Context survey should be done and any other member in the family found to have active TB should be counselled to attend TB clinic for therapy.
  • Need for compliance should be emphasised
  • Drug toxicity and side effects must be explained.
  • Neurological deficits may appear even in a patient on therapy.

References

  1. Neurotuberculosis with Special Reference to Management of Tubercular Meningitis in Children, 1982, Bull. Int. Union Tuberc, 57, 43-48.
  2. Three Chemotherapy Studies of Tubercular Meningitis in Children. Tubercle 1986, 67: 17-29.
  3. Tuberculosis in Children. A Statement of Scientific Committee of IUATLD, 1991 Bull Int Union Teberc Lung Dis, 66: 61-67.
  4. Treatment of Tuberculosis: Consensus Statement of IAP Working Group. Indian Paediatric 1997, 34: 1093-96.
  5. Jacob RF, Sunokorn P. Tuberculous Meningitis in Children: An Evaluation of Chemotherapeutic Regimens,1990 Ann Rev Resp Dis, 141: (5) A 337.
  6. Dexamethasone Adjunctive Treatment for Tuberculous Meningitis. Paediatric Inf Dis 1993, 39: 361-64.
  7. Mycobacterial Infections. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 885-897.

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Acute Meningoencephalitis

Acute meningoencephalitis is an acute inflammatory process involving meninges and brain tissue, due to infectious causes. The common aetiological agents are viruses and bacteria. Children of any age may be affected.

Salient features

Fever, headache, vomiting, irritability altered state of consciousness, signs of meningeal irritation and seizures. Children of any age may be affected.

  • CSF examination differentiates the viral from bacterial cause of acute meningoencephalitis. (Table 1).

Treatment

Supportive treatment is the mainstay of therapy and is started immediately.

  1. Maintain airway, breathing and circulation.
  2. Control of seizures with IV injection of Diazepam 0.2 to 0.4 mg/kg stat followed by Inj Phenytoin 10-20 mg/kg stat followed by 5 mg/kg/day in divided doses.
  3. Increased Intra-cranial tension is treated by proper positioning of patient with head elevated at 15 -30° position, fluid restriction to 2/3rd of maintenance, 20% Mannitol 5 ml/kg over 10-15 min followed by 3 ml/kg every 6 hourly for 48 hours and then SOS.
    Or
    Acetazolamide 50-75 mg/kg/day in 3 divided doses through feeding tube
    Or
    Glycerine 1 ml/kg/day through feeding tube may be added if increased intra cranial tension persists.
  4. Fever is controlled as given in section on fever.
    (CAUTION: Never give aspirin ).
  5. The intravenous fluid is given at 2/3 of the maintenance requirement initially. The electrolyte concentration of the blood is monitored very closely. Any imbalance is treated promptly. Fluid restriction is not done if patient is dehydrate or is in shock.
  6. Feeding: Initially the patient is kept nil orally for first 24-48 hours. Later on the feeding is guided by the level of sensorium. A tube feeding is helpful for feeding as well as for giving medicines.


Table 1. CSF findings in meningoencephalitis.

Pressure (mmH2O) Leucocytosis (mm3) Protein (mg/dl) Glucose (mg/dl)
Normal 50-80 <5, >75% Lymphos 20-45 > 50 or 75% serum glucose
Acute bacterial meningitis Usually elevated (100-300) 100-10,000 PMN’s* predominate 100-500 Decreased (<40)
Acute viral meningoencephalitis Normal or elevated Rarely > 1000 PMN’s early but Lymphos predominate in the most of the course 50-200 Normal rarely decreased
Tubercular meningoencephilitis Usually elevated 100-500 PMN’s early but later lymphocytes predominate 100-3000 <50

*PMN’s = Polymorphonuclear leucocytes

Specific treatment

Until a bacterial cause is excluded, parenteral antibiotic therapy should be administered. The choice of antibiotics depends upon age of the patient and prevalence of organism in the area.

Age 0-3 months

  1. Inj Cefotaxime 200 mg/kg/day IV in 4 divided doses for 14 days.
  2. Inj Ampicillin 300 mg/kg/day IV in 4 divided doses for 14 days.

Age 3 months – 12 years

  1. Inj Ceftriaxone 100 mg/kg/day IV in 2 divided doses for 10 days
    Or
    Inj Cefotaxime 200 mg/kg/day IV in 3 divided doses for 10 days
    Or
    Inj Ampicillin 300 mg/kg/day IV in 4 divided doses for 10 days
  2. Inj Chloramphenicol 100 mg/kg/day in 4 divided doses for 10 days

If meningococcus is suspected/isolated Inj Penicillin G 300,000 – 400,000 IU/kg/day in 4 divided doses for 7-10 days.

Viral meningoencephalitis

Herpex simplex virus: (generally diagnosed by focal encephalitis or CT scan) Inj Acyclovir 30 mg/kg/day in 3 divided doses for 145-21 days. Non HSV viral encephalitis is treated by supportive therapy only.

The lumbar puncture is repeated at 48 hours to see the response. However, if the patient is improving well, a repeat lumbar puncture may not be necessary.

Advise at discharge

  1. Regular follow up for neurological assessment including deafness is advised.
  2. Anticonvulsant therapy to be continued if seizures are recurrent during course of meningitis.
  3. Children with sequated would require assessment of handicap and multidisciplinary management. Occupational/physiotherapy may be taught during hospital stay it self.

References

  1. Central Nervous System. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 751-761.
  2. Paediatric Infectious Diseases; 4th Edition pp 457-468.
  3. Acute Viral Encephalitis in childhood. BMJ 1995; 310: 139-140.

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Febrile Seizures

Febrile Seizures are brief (2-5 min), generalized tonic-clonic and self limited seizures followed by a brief post-ictal period of drowsiness, in an otherwise healthy, febrile child of 6 months to 5 years of age, without any evidence of underlying neurological disease. They are the most common seizure disorder during childhood, with a uniformly excellent prognosis.

They occur rarely before 6 months and after 5 year of age. The peak age of onset is approximately 14 -18 months of age, found in 3-4% of young children. There is a strong family history of febrile convulsions in siblings and parents, suggesting a genetic predisposition. Except for the cases at high risk, simple febrile seizures rarely develop into epilepsy.

Salient features

  • Febrile seizures usually occur when the temperature is rising rapidly, to generally 390C (1020F) or more of core temperature.
    They are of two types:

      • Typical (Simple) febrile seizure occurs on day 1 of fever, does not last for more than 10 minutes; generalized tonic-clonic; generally not more than one episode within 24 hours.
      • Atypical or complex febrile seizure may persist for more than 15 minutes; it could be focal in nature; more than one episode of seizure in 24 hours; associated with abnormal neurological findings or deficits. An organic cause such as an infectious or toxic process, should be considered and investigated.
  • Lumbar puncture: A lumbar puncture with examination of CSF is essential to rule out possibility of meningitis in cases with first episode of febrile seizures.
  • EEG is not required in case of simple febrile seizures. However, in cases with atypical febrile seizure or in a child with high risk for developing epilepsy, it may be helpful.
  • High risk for developing epilepsy, include a positive family history of epilepsy, initial febrile convulsion prior to

Treatment

Careful search for the cause of fever and treatment of fever (see section on fever).

Most febrile seizures are brief and would be over by the time a child is brought to the doctor or health facility.

Nonpharmacological

Clear the airway, semi-prone lateral position and oxygen therapy.

Pharmacological

In cases presenting with seizures, the mainstay of management is prompt administration of anticonvulsants.

The best drug is Diazepam in a dose of 0.3 mg/kg by slow intravenous or rectal route. It can be repeated if seizures do not subside (per rectal dose may be given up to 0.5 mg/kg/dose).

Intermittent prophylaxis (during febrile illness)

It is a safe and effective method of prophylaxis. Tab/Syp Diazepam 0.3 mg/kg/dose every 8 hours (1 mg/kg/day) for 2-3 days of febrile illness, started on the day of onset of fever. Dose can be adjusted if over sedation or ataxia noted.

Continuous prophylaxis

Phenytoin and carbamazapine are ineffective for prophylaxis and phenobarbitone has serious effects on cognitive function. Sodium valproate is effective but potential risk do not justify its use.

Patient/parent education

  • The parents and caretaker should be assured of the benign nature of the disease and should be told that no neurological deficit or mental retardation occurs as a result of simple febrile seizure.
  • They should be taught about control of fever at home. They can be taught to give diazepam per rectally at home.
  • Routine immunization as per schedule should be followed. After DPT vaccination, oral paracetamol 15 mg/kg/dose every 6th for 2 or 3 days and similarly, after measles vaccination, oral paracetamol in the same dose started on the 4th day from the day of vaccination and given for 3 to 4 days to avoid precipitation of febrile seizures.

References

  1. Febrile Seizures. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 1818-1819.
  2. Protocol for Childhood Neurological Diseases: Manual by Expert Group of SAARC Countries, 1999.
  3. Febrile Seizures: An update, Indian Paediatrics 1995, Vol 32: 566-572.
  4. Long-term Outcome of Prophylaxis for Febrile Seizures. Arch Dis Child 1996, 74:13-16.
  5. Recurrence Risk after First Febrile Seizure and Effect of Short-term Diazepam Prophylaxis. Arch Dis Child 1985; 60:1045-1049.

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Neurocysticercosis

The neurocysticercosis is the disease produced by invasion of the CNS by the cystic stage (cysticercus) of pork-tapeworm ( Taenia solium). It is the most common parasitic cause of CNS disease and is prevalent in every continent except Antarctica. Humans acquire the disease when they ingest the food or water contaminated with the eggs of T. solium.

Salient features
  • The clinical features depend upon site and number of cysts in the CNS, and the inflammatory response of the CNS. It can present as a ‘silent’ case on one hand to encephalitis like symptoms. On the other hand any neurologic, cognitive, or personality disorder in an individual from an endemic area may represent neurocysticercosis. However, the seizures, either focal or generalized, remain the most common form of presentation.
    Less common is the feature of meningeal irritation, hydrocephalus or increased intra-cranial tension. Decreased visual acuity may be seen in ocular cysticersosis. In spinal neurocysticercosis, patients present with evidence of cord compression, nerve root pain, transverse myelitis, or meningitis.
  • Imaging studies (CT & MRI) and serologic tests (ELISA or immunoblot) are the only way to confirm the diagnosis. Cystic lesions with or without enhancement and calcifications are the commonest findings.

Treatment

Issues concerning when and how to treat are not completely resolved. Parenchymal lesions resolve even without treatment. Anticonvulsant drugs may be the only symptomatic therapy required. However, some workers suggest cysticidal therapy because it leads to rapid resolution.

Pharmacological

  1. Tab Albendazole 15 mg/kg/day in 2-3 doses per day for 15 days, taken with fatty meals.
    Or
    Tab Praziquantel 50 mg/kg/day in 3 divided doses for 15 days.
    Albendazole is as effective as Praziquintal.
    Patients should be monitored carefully for development of raised ICP.
    Tab Prednisolone 1-2 mg/kg/day started 2-3 days prior to cysticidal drugs and continued for 5-7 days may prevent these effects.
  2. Anti-convulsants, such as carbamazepine or phenytion should be used in appropriate doses to control the seizures. An optimum duration of therapy has not been settled. However, a seizure free interval for even one year, may be taken as indication to taper off the therapy (for details see section on epilepsy; status epilepticus).
  3. Corticosteroid Currently, the use of corticosteroid is limited to following category of patients only:
    i. For patients who develop signs of increased intra-cranial tension during treatment.
    ii. Large sub-arachnoid cysts. (these cases have risk of developing cerebral infarcts due to occlusive endarteritis).
    iii. Encephalitis like features.
    iv. Cysticercal angitis.

Surgical treatment

  1. A ventricular shunt must be placed if there is evidence of hydrocephalus. This should precede the medical treatment.
  2. Surgical intervention is also required for removal of large solitary cyst for decompression, removal of mobile cysts causing ventricular obstruction, and some cases that fail to respond to medical therapy. (spillage of cyst contents is not seen in these cases as is seen in cases of echinococcosis ).
  3. Ocular cysticercosis should be treated surgically only; enucleation is frequently required.

Patient/parent education

  • Minimising the opportunities for ingestion of facally derived eggs by means of good personal hygiene, effective faecal disposal and treatment and prevention of human intestinal infections.
  • All members of a family of an index case of cysticercosis should be examined for the presence of eggs or signs of disease.
  • Prolonged freezing or thorough cooking of food items, pork in this case, will kill the parasite.

References

  1. Cysticercosis. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 1078-1079.
  2. Therapy for Neurocysticercosis. Clin Inf Dis 1993, 17:730-735.
  3. Medical Treatment of Neurocysticercosis. Arch of Neurol 1995, 324: 1137-1139.
  4. Albendazole Versus Praziquentel in the Treatment of Cerebral Cysticercosis. Transactions of Royal Soc Trop Med & Hyg 1991; 85: 244-247.
  5. Dexamethasone with Albendazole. J Neurol 1990; 237: 279-280.
  6. Etiology and Management of Single Enhanced CT lesion. Act Neurol Scand 1991, 84: 465-470.

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Nephrotic Syndrome (NS)

Nephrotic syndrome is an important chronic disorder in children. It can be primary (idiopathic) or secondary (SLE, Henoch Shonlein purpura, amyloidosis etc). About 90% children with idiopathic nephrotic syndrome have ‘minimal lesion’ on renal histology and respond promptly to corticosteroids. Approximately three fourth patients have one or more relapses. Steroid toxicity and frequent serious infection complicate such cases.

Salient features

  • Heavy proteinuria, hypoalbuminaemia (S. Albumin <2.5 g/dl), hyperlipidaemia (S. Cholesterol >200 mg/dl) and oedema. Dipstick or heat coagulation of urine shows 3+/4+ proteinuria.
  • Investigations which help in diagnosis and management are urine analysis, blood counts, S. cholesterol, S. proteins, blood urea, S. creatinine, urine culture, X-ray chest, Montoux, HBsAg

Figure 1. Treatment of nephrotic syndrome without hypertension, haematuria and azotaemia.

Treatment

Definitions useful for guiding treatment are as follows:

Remission – Urine albumin nil or trace (or proteinuria <4 mg/m2/h) for 3 consecutive days.
Relapse – Urine albumin 3+ or 4+ (or proteinuria >40 mg/m2/h) for 3 consecutive days having been in remission previously
Frequent relapses – Two or more relapses in six months of initial response, or more than three relapses in any twelve months
Steroid dependence – Two consecutive relapses when on alternate Day steroids or within 14 days of its discontinuation
Steroid resistance – Absence of remission despite therapy with 4 weeks of daily prednisolone in a dose of 2 mg/kg per day.

Nonpharmacological

  • Avoid saturated fats
  • Adequate proteins, and salt restriction only during oedema, avoid extra salt
  • Good physical activity

Pharmacological

Investigations to rule out infection should be done before starting treatment with steroids i.e. urine culture & sensitivity, Montoux, X-ray chest, Hb, HbsAg.

Treatment of 0edema – in case of moderate to severe edema

  1. Tab Frusemide 1-3 mg/kg/day in 1-2 doses given preferably in the morning. Treatment of nephrotic syndrome without hypertension, haematuria and azotemia is given in Figure I. Presence of the these features points towards nonminimal change. If oedema does not respond Tab Spironolactone 2-4 mg/kg/day as single dose preferably in the morning. A gradual reduction of oedema is better. Patient with refractory severe oedema should be referred to a higher centre.

Monitoring

  1. Urine output, weight record
  2. Blood pressure
  3. Urine albumin daily till remission

Infection in nephrotic syndrome

  1. Patients of nephrotic syndrome with Montoux positive but no evidence of disease should be put on INH prophylaxis for 6 months.
  2. Absence of florid symptoms and signs may delay the diagnosis of serious infections like peritonitis and cellulitis in nephrotics. Systemic antibiotics should be used aggressively if infection is suspected.

Indications for kidney biopsy (to be carried out at tertiary care level)
At onset
<1 year or >15 years persistant microscopic or gross haematuria, low serum C3; substained hypertension; renal failure not attributable to hypovolemia; or suspected secondary causes of nephrotic syndrome

After initial treatment
Proteinuria persisting despite 4 weeks of daily corticosteroid therapy Before starting treatment with cyclosporine-A Frequently relapsing or steroid dependent nephrotic syndrome

Indications for referral to a higher centre

  • Onset <1 year of age
  • Nephrotic syndrome presenting with hypertension, persistent microscopic or gross haematuria, or impaired renal function
  • Complications like refractory oedema, thrombosis, severe infections and steroid toxicity
  • Resistance to steroids: initial or late
  • Frequently relapsing or steroid dependent nephrotic syndrome

Patient/parent education

  • Reassurance that despite a relapsing course progression to end stage renal disease is rare.
  • Urine examination by sulfosalicylic acid (SSA), dipstick or boiling should be taught
  • Maintain a diary showing proteinuria and medication received
  • Ensure normal activity
  • Protection against infection

References

  1. Consensus Statement on Management of Nephrotic Syndrome. Indian Paediatric Nephrology Group, Indian Academy of Paediatrics, Indian Paediatrics, 2001, 38: 975-896.

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Acute Glomerulonephritis (Post-Streptococcal)

It follows streptococcal infection of throat or skin by 1-2 weeks. Complications like congestive heart failure or encephalopathy may occur in a few patients. Diagnosis is clinical with urine showing RBC’s, WBC and mild proteinuria. Serum C3 levels may be low. Disease is self limiting and generally resolves in one month, however, microscopic urinary changes may persist up to one year.

Salient features

  • Sudden onset of gross haematuria, proteinuria, oedema, hypertension, oliguria and other features of renal insufficiency.

Treatment

Child should be admitted for monitoring and treatment, if complications occur.

Nonpharmacological

  • Routine activity need not be restricted unless features of acute renal failure or severe hypertension occur.
  • Diet is restricted like in acute renal failure

Pharmacological

There is no specific treatment
Treatment of hypertension

  1. Inj. Fursemide (40 mg) 1-2 mg/kg/day in 2 divided doses till oliguria lasts
  2. Cap. Nifedipine 0.25 mg/kg SOS
  3. Inj. Procaine penicillin 4 lac units once daily if evidence of sore throat or skin infection

Monitoring and follow up with

  • Regular weight record, strict intake-output chart, blood pressure recording should be done regularly.
  • Refer to a higher centre if hypertension, haematuria or renal failure are not manageable.

Patient/Parent education

  • Parents should be explained the natural course. More than 95% recover within 2-4 weeks. Only a few patients may end up with chronic renal insufficiency.

References

Gross or Microscopic Haematuria. In: Nelson’s Text Book of Paediatrics, Behrman, Liegman, Jenson (eds), 16th Edition, 1999; pp 1581-1584.

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Urinary Tract Infection (UTI)

Urinary tract infection (UTI) is a common bacterial infection in infants and children. One percent boys and 3-5% girls below 14 years develop UTI. Risk of UTI is higher in children with congenital urinary tract anomalies, chronic diarrhoea and malnutrition.

Salient features

  • Symptoms are nonspecific. In neonates, it presents as a part of septicaemia, in infants and young children with fever, diarrhoea, vomiting also pain and poor weight gain.
  • Older children may have burning, urgency, frequency, flank pain, turbid urine and recent onset enuresis. Diagnosis is confirmed by growth of significant number of organisms of a single species in the urine (Table 1).

Treatment

Nonpharmacological

Maintain adequate hydration and encourage liberal fluid intake to alleviate dysuria
(Note: Alkalinization of urine is not necessary)

Pharmacological

Therapy should be started after obtaining urine culture. Patient’s age, degree of toxicity, state of hydration, ability to retain oral intake and the likelihood of compliance with medication help in deciding therapy.

Complicated UTI and/or age less than 3 months

  1. Inj. Ampicillin 100 mg/kg/day IV in 3 divided doses for 10 to 14 days
  2. Inj. Gentamicin 5-6 mg/kg/day in 2 divided doses for 10 to 14 days
    Or
    Inj. Cefotaxime 100-150 mg/kg/day IV in 3 divided doses for 10 to 14
    days
    Or
    Inj. Ceftriaxone 75-100 mg/kg/day IV in 1-2 divided doses for 10 to 14
    days


Table 1. Interpretation of urine culture

Method of collection Colony count Probability of infection
Suprapubic aspiration Urinary pathogen
in any number
99%
Urethral catheterization >50 x 103 CFU/ml 95%
Midstream clean catch >105 CFU/ml 90-95%

CFU: colony forming units.

Definitions:

Significant bacteriuria Colony count of > 105/ml of a single species in a midstream clean catch sample
Asymptomatic bacteriuria Presence of significant bacteriuria on two or more specimens iln a child with no symptoms
Recurrent UTI Second attack of UTI
Complicated UTI Presence of fever > 38.5° C, toxicity, persistent vomiting, dehydration and renal angle tenderness
Simple UTI UTI with low grade fever, dysuria, frequency, urgency but none of the above symptoms

Complicated UTI and age 3-6 months

  1. Inj. Gentamicin 5-6 mg/kg/day IV in 2 divided doses for 10 to 14 days UTI > 3 months.
  2. Syp. Amoxycillin 30-50 mg/kg/day in 3 divided doses for 7 to 10 days.
    Or
    Syp. Cotrimoxazole (Trimethoprim) 6-10 mg/kg/day in 2 divided doses for 7-10 days.
    Or
    Syp. Cephalexin 50-70 mg/kg/day in 3 divided doses for 7-10 days.

(CAUTION: Quinolones should be avoided as first line medication; their use is guided by results of culture and sensitivity)

Nalidixic acid or Nitrofurantoin should not be used to treat UTI since they do not achieve therapeutic concentration in renal parenchyma and blood stream.

Monitoring

An abdominal ultrasound examination and repeat urine culture are necessary in patients who fail to show clinical response (reduction of fever and toxicity) within 48 hours of initial treatment.

Workup of a case of first UTI is shown in Figure 1. Child with more than one episode should be worked up for cause of recurrent UTI. Each episode is treated as mentioned above but child should be investigated in detail with ultrasound, MCU and DMSA scan and prophylaxis for recurrence as in Table 2 and 3.

Figure 1. Workup of a cases of first UTI

Antibiotic prophylaxis in recurrent UTI

Long term, low dose antibacterial prophylaxis is used to prevent recurrent febrile UTI.


Table 2. Antimicrobials for prophylaxis of UTI

Drug Dose (mg/kg/day) Remarks
Cotrimoxazole 1-2 (trimethoprim) Avoid in infants <3 months age and G-6PD deficiency
Nitrofurantoin 1-2 Gastrointestinal upset; avoid in infants < 3 months age, G-6 PD deficiency and renal insufficiency
Cephalexin 10 Drug of choice in first 3-6 months of life


Table 3. Indications and duration for antimicrobial prophylaxis

Findings
First UTI
Age Duration
Reflux and renal scar present All Till 5 years of age*
No reflux but renal scar All Six months and re-evaluate**
No reflux, no renal scar < 2 years
> 2 years
Six months and re-evaluate**
No prophylaxis
Recurrent UTI
(without reflux or scar)
All Six months

* Child >5 years of age at initial evaluation prophylaxis for 12-18 months, reevaluate
**DRCG/MCU to look for vesico urethral reflux (VUR), which might have been missed on initial evaluation. Prophylaxis is stopped if VUR is not detected.
Note: Grade IV (bilateral) and Grade V – prophylaxis given up to 1 year, then surgery is indicated.

References

Consensus Statement on Management of Urinary Tract Infections. Indian Paediatric Nephrology Group, Indian Academy of Paediatircs. Indian Paediatrics, 2001, 38: 1106-1115.

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Hypothyroidism

Hypothyroidism is characterized by decrease in the function of the thyroid glands. Most cases in children are due to congenital hypothyroidism causes such as aplasia, hypoplasia or ectopia of thyroid gland. Common causes of acquired hypothyroidism are iodine deficiency, lymphocytic thyroiditis and following irradiation of cervical region for malignant disorders. Diagnostic studies and treatment are same as that for congenital hypothyroidism.

Salient features

  • Congenital hypothyroidism is difficult to diagnose in neonatal period as the symptoms and signs may not be fully developed.
    However, prolongation of physiological jaundice and feeding difficulty in the form of sluggishness and choking during feeding occur. Infants cry less, sleep more and have constipation, abdominal protuberance and umbilical hernia. Infants with these features should be screened by thyroid function tests to avoid delay in diagnosis. Gradually the features of physical and mental retardation become more obvious which can be severe.
  • The diagnosis is based on demonstration of low serum of T4. Serum T3 levels may be normal and are not useful for diagnosis. In primary hypothyroidism, TSH is elevated. Radionuclide scans are not essential for diagnosis but help to delineate the exact aetiology.

Pharmacological

Initiation of therapy: L-thyroxine (Tab., 50 and 100 mcg).
Initial dose in neonatal period is 10-15 mcg/kg/day (usually 37.5-50 mcg per day), given as a single daily dose half an hour before food. The tablet can be crushed and mixed in expressed breast milk or any other liquid for small infants.

Treatment is required life long and the requirement keeps changing with increasing age. In later part of infancy dose decreases to 5-6 mcg/kg/day then to 3-4 mcg/kg/day in children and the adult dose is 2 mcg/kg/day.

Assessment of response: Early response is evident in initial few weeks and consists of symptomatic improvement in alertness, relief of constipation, improvement in appetite and feeding. Increased linear growth and osseous maturation is seen over next few months.

  • The child should be followed clinically every month for 6 months, 3 monthly till 2 years and thereafter once to twice every year. Recurrence of symptoms such as lethargy, constipation and weight gain suggest undertreatment and diarrhoea, palpitations, increased appetite and weight loss suggest overdosing.
  • Periodic check on thyroid function tests is needed (6 monthly or so).
    Serum T4 level should be maintained in upper normal range and TSH levels suppressed to normal.
  • After few months of starting therapy, sometimes features suggestive of raised intracranial tension such as headache and vomiting may appear. The patient should be immediately admitted and treated.

Patient /parent education

  • Patient should be told about the need for life long administration of the drug.
  • Regular follow up at the interval described above is important for proper monitoring and dose titration.
  • Clinical symptoms of under or overdosage, including the danger signs of pseudotumour cerebri should be explained.

see also Hypothyroidism in chapter-11

References

Hypothyroidism. In: Nelson’s Text Book of Paediatrics. Behrman, Liegman, Jenson (eds), 16th Edition, 1999; pp 1698-1704.

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Diabetes Mellitus (DM)

Most of the cases of DM in children are of insulin dependent diabetes Mellitus (IDDM) and have hyperglycaemia with glucosuria.

Salient features

While some cases present with classical symptoms of polyphagia, polydipsia, polyuria and weight loss, many children at the onset present in the state of diabetic ketoacidosis (DKA).
A minority of cases, while asymptomatic are detected to have glucosuria and hyperglycaemia.
Diagnosis of DM is made by demonstration of hyperglycaemia (random plasma glucose more than 200 mg/dl). Following cut off

 

Time Normal range DM diagnosis
Fasting 70 -105 mg/dl > 115 mg/dl
60 minutes 120 -170 mg/dl > 200 mg/dl
90 minutes 100- 140 mg/dl > 200 mg/dl
120 minutes 70- 120 mg/dl > 140 mg/dl
  • Patients during DKA have moderate to severe dehydration with plasma glucose levels usually more than 300 mg/dl, metabolic acidosis, ketonuria and various electrolyte disturbances.

Treatment

Nonpharmacological

Diet

  • Regularity of eating pattern is very important so that diet and insulin dosing is synchronised.
  • General nutritional guidelines are followed.
  • Calorie mixture should have 55% carbohydrates, 30% fat and 15% proteins.
  • Avoid carbohydrate with refined sugars to prevent metabolic swings. Carbonated drinks should be of sugar free variety.
  • Fats derived from animal sources to be reduced and should be replaced by fats of vegetable origin.
  • Calorie intake should be split as 20% breakfast, 20% lunch, 30% dinner and 10% each for 3 snacks at mid morning, mid afternoon and evening.

Physical activity and fitness

  • Usual exercises advised to diabetic children and adolescents include vigorous walking, jogging, swimming, tennis etc. Though, diabetics can undertake any exercise, but unusual exercise may require modification in insulin dosing. For the schedule day of unusual exercise, insulin dose may be reduced by 10-15%.

Pharmacological

Initial therapy

Treatment is initiated in the hospital with fast acting (regular) insulin.
At the onset of DM (or after recovery from DKA) the dose of insulin is 0.5-1.0 unit/kg/day.
Inj. Regular insulin 0.1-0.25 units/kg subcutaneous injections are given 6-8 hourly before meals.
Simultaneous blood glucose level monitoring is done. One to two days therapy is required to find out total daily insulin requirement. Once the patient stabilises on 6 hourly insulin injections, the patient is switched over to “2 daily injections” schedule.
In “2 daily injections” schedule, the insulin is administered as follows:

  • Combinations of intermediate acting (usually lente) insulin and fast acting (regular) insulin is used in the ratio of 2-3:1. Two third of total daily -dose is injected before breakfast and one third before dinner. Each injection has combination of both types of insulin e.g., total dose of insulin is 30 units -20 units (14 units lente and 6 units regular) are injected before breakfast and 10 units (6 units lente and 4 units regular) are injected before dinner.
  • Blood glucose levels are monitored before each meal and the dose of insulin adjusted accordingly. Blood glucose levels should ideally be 80 mg/dl fasting and 140 mg/dl after meals (acceptable range between 80 -240 mg/dl). Early morning 3 AM blood glucose level should be more than 70 mg/dl.

Following modification in the insulin doses will be required depending upon the blood glucose levels:

Time and blood glucose Type and time of insulin modified
1. High fasting blood glucose Evening lente insulin is increased by 10%
2. High noon blood glucose Morning regular insulin is increased by 10%
3. High pre dinner blood glucose Morning lente insulin is increased by 10%
4. High pre bed time blood glucose Evening regular insulin is increased by 10%
5. Low fasting blood glucose Evening lente insulin is decreased by 10%
6. Low noon blood glucose Morning regular insulin is decreased by 10%
7. Low pre dinner blood glucose Morning lente insulin is decreased by 10%
8. Low pre bed time blood glucose Evening regular insulin is decreased by 10%
  • Any increase or decrease in insulin dose is by 10- 15%. Generally not more than 6 units.
  • After initial stabilisation, newly diagnosed cases may have gradual decline in insulin requirement even upto 0.5 units/kg/day. This may persist for several weeks to several months.
  • Decrease total dose of insulin by 10% at the time of discharge from hospital as the increased activity at home will decrease the insulin requirement.

Assessment of diabetic control or response to therapy

  • Blood glucose estimation should be done before each meal and at bed time in the first few weeks after diagnosis. After stabilisation, it can be reduced to twice a week.
  • Periodically blood glucose estimation at 3-4 AM is required to detect early morning hypoglycaemia.
  • Urine for sugar is also monitored initially 3-4 times daily before meals.

This can be done less frequently after initial few weeks, preferably on the days when blood sugar is not done.

  • Urine for ketones once daily should be done.
  • Glycosylated haemoglobin (HbA1 C) estimation-once every 3 months.
    – HbA1C levels of 6-9% represent very good control of diabetes, 9 -12% show fair control and above 12% represent poor control.
  • Serum lipids -cholestrol, HDL, LDL, VLDL, triglycerides and urine for protein should be done once every year. Serum cholestrol should be less than 200 mg/dl, LDL less than 130 mg/dl and triglycerides less than 140 mg/dl.
  • Thyroid function tests should be done once every year to detect concomitant hypothyroidism.

For management of hypoglycemia and diabetic ketoacidosis see chapter 11 on hormonal disorders.

Patient/parent education

Patient/parents should be taught self diabetic care which should include:

  • Technique of measuring insulin in the syringe.
  • Importance of drawing insulin always in the same sequence (usually regular insulin first) so that same type of insulin is left over in the dead space of the syringe.
  • Explain technique of subcutaneous injections and importance of rotating the injection sites – arms, thighs (upper and lower), buttocks and abdomen.
  • Monitoring urinary sugar – by the double void method (void 30 minutes before the test void).
  • Blood sugar monitoring, maintaining the records of treatment and sugar levels
  • Adherence to diet.
  • Regular exercise.
  • Recognising the symptoms of hypoglycaemia and its home management.

References

Diabetes Mellitus. In Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 1767-1791.

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Rheumatic Fever And Rheumatic Heart Disease

Rheumatic fever is a multi system inflammatory disease that occurs as a delayed sequalae to group A Beta haemolytic streptococcal pharyngitis.
The disorder is largely self limited and resolves without sequelae but chronic and progressive damage to heart valves lead to rheumatic heart disease (RHD).

Salient features

  • Presence of two major or one major and two minor criteria in addition to evidence of recent streptococcal infection (raised ASO titer, positive throat swab or recent scarlet fever) is necessary for diagnosis of Rh fever
  • Major criteria: arthritis, carditis, subcutaneous nodules, chorea, erythema marginatum
  • Minor criteria: fever, arthralgia, elevated acute phase reactants (ESR, CRP) and prolong-ed PR interval
  • RHD most frequently affects mitral and aortic valve. Isolated aortic valve involvement is rare and tricuspid and pulmonary valve involvement is unusual.
  • Complications of RHD are cardiac failure and infective endocarditis

Treatment (Acute rheumatic fever)

Nonpharmacological

Avoid vigrous activity till ESR normalizes. In severe CHF, salt restriction, fluid restriction, upright posture. Protect patient from getting injured in chorea.

Pharmacological

  1. In arthritis only:
    Tab. Aspirin 90-120 mg/kg/day in 4 divided doses for 10-12 weeks to be given after meals. During therapy monitor for tinnitus, deafness, respiratory alkalosis/acidosis.
    In carditis without CHF:
    As above.
    In carditis with CHF: Tab. Prednisolone given after meals in dose of 2.5 mg/kg/day 2 divided doses for 3 weeks then tapering over next 3 weeks. During tapering add Aspirin as above and continue it for 4-6 weeks. Monitor blood pressure and blood sugar.
  2. For treatment of CHF see section on CHF.
  3. In Chorea: Tab. Haloperidol 0.05 mg/kg/day divided doses 2-3 divided doses; dose titrated according to response.
  4. Inj. Procaine penicillin 4 lac units IM twice daily for 10 days.
    Or
    Inj. Benzathine penicillin G 1.2 mega units (>27 kg), 0.6 mega units
    (<27 kg) IM single injection.
    Or
    Tab. Penicillin V 125-250 mg twice daily for 10 days.
    Or
    Tab. Erythromycin 40 mg/kg/day 3 times a day for 10 days.

Usually joint pains disappear within 24 to 48 hours, tachycardia settles, pericardial friction rub if present disappears and gradually ESR comes to normal. In established cardiac lesions with CHF not controlled by medical management patient should be referred to a higher centre for surgical intervention.

For secondary prevention (for prevention of recurrences)

Inj. Benzathine penicillin G 1.2 mega units (>27 kg), 0.6 mega units
(<27 kg) IM every 3 weeks.
Or
Tab. Penicillin V 250 mg 2 times a day.
Or
Tab. Sulfadiazine 500 mg once daily.
Or
Tab. Erythromycin 250 mg 2 times a day.
Duration of secondary prevention is individualized. In patients with established valvular lesion prophylaxis should be given for life long or at least till theage of 35 years. In others it is given for atleast 5 years after the most recent attack or till the age of 18 years which ever comes first. In acute rheumatic fever observe for appearance of valvular lesions (most common in the first four weeks of disease) and in RHD for effort intolerance, signs and symptoms of CHF, echocardiographic studies of cardiac functions

Patient/parent education

  • Early and adequate treatment of sore throat.
  • Emphasize the importance of regular prophylaxis with benzathine penicillin.
  • Patients with RHD should avoid contact with sore throat cases and if possible environmental modification e.g., avoid overcrowding.

References

  1. Rheumatic Fever. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 754-760.
  2. Eugene Braunwald: Heart Disease 56: 1721,1992.

>> See also Rheumatic Fever in chapter-3

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Cardiac Failure

Cardiac failure is defined as a state in which the heart cannot deliver an adequate cardiac output to meet the metabolic needs of the body. Clinical presentation is dependent on age and degree of cardiac reserve. Common causes according to age of presentation are:
Neonate – Severe anaemia, heart block, congenital heart disease e.g. hypoplastic left heart, co-arctation, left to right shunt and large mixing cardiac defects.
Infant – Left to right shunt, supraventricular tachycardia
Child – Rheumatic fever, myocarditis, cardiomyopathy, acute hypertension e.g., acute glomerulonephritis.

Salient features

  • Exertional dyspnoea, poor weight gain, feeding difficulties, breathes too fast and better when upright, persistent cough and wheezing, excessive perspiration and irritability, puffiness of face and pedal oedema
  • Tachypnoea, tachycardia, small volume pulse, peripheral cyanosis, pedal/facial/ sacral oedema, hepatomegaly, raised JVP (appreciated well in older children), gallop rhythm, cardiomegaly and failure to thrive.

Treatment

Identify and treat the underlying cause.

Nonpharmacological

Restricted activity and bed rest with upright posture depending on cardiac reserve.


Figure 1. Alogrithm for treatment of congestive heart failure

In severe CHF, dietary modifications in infants by increasing calories per feed. Breast-feed supplementation, naso gastric feed to avoid the exertion of active feeding.
No added salt in diet and fluid restriction and cold sponging in case of fever.

Pharmacological

Algorithm for treatment is shown in Figure 1.

  1. Elixir/Tab. Digoxin (Elixir 0.25 mg/5 ml, Tab. 0.25 mg)
    Method of digitalization: 0.5 x digitalization dose initially, 0.25 x digitalizing dose 8 and 16 hours later.
    Digitalizing dose: newborn = IV, IM: 0.010 – 0.030 mg/kg divided or orally: 0.040 mg/kg divided in fractions.
    Infants = IV, IM 0.030 – 0.040 mg/kg or orally 0.050 mg/kg in fractions.
    Childrens = IV, IM, PO: 0.010 – 0.015 mg/kg in fractions
    For maintenance: begin maintenance dosage 24 hours after 1st fraction of digitalizing dose. Newborn = PO: 0.005 – 0.010 mg/kg/24 hours, divided every 12 hours. In infants and children orally 0.002 – 0.005 mg/kg/24 hours divided every 12 hours.
    (CAUTION: Avoid hypokalaemia during therapy with digoxin)
  2. Tab. Frusemide 1-2 mg/kg every 12 hourly. (may need K supplement).
    Or
    Tab. Chlorothiazide 20-50 mg/kg/day in 2 divided doses.
    Or
    Tab. Spironolactone 1-3 mg/kg/day in 2 divided doses.
  3. In cases with regurgitant cardiac lesions like severe MR where reduction in after load is required
    Tab. Captopril 0.1-0.2 mg/kg/dose 8-12 hourly (maximum 4 mg/kg/day)
    Or
    Tab. Enalapril 0.08-0.5 mg/kg/dose 12-24 hourly (maximum 1 mg/kg/ day)
  4. Patients with hypotension and low cardiac output should be referred to a higher center)
    Inj. Dopamine infusion (40 mg/ml) 2-20 mcg/kg/min prepared in normal saline or 5% dextrose. Hypovolaemia should be corrected before infusion is started and BP is monitored during the infusion.
    Or
    Dobutamine infusion (250 mg/5 ml) 2- 20 mcg/kg/min. Both the drugs can be used simultaneously to have added response because of different mechanism of actions.

Patient/parent education

  • Decreased salt intake should be emphasised
  • Sufficient rest and adequate sleep must be emphasised. Strict bedrest is necessary only in severe cases.
  • Semi-upright position during sleep may make the patient more comfortable.

References

  1. Heart Failure. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 1440-1445.
  2. Eugene Braunwald: Heart Disease 56: 1721,1992.

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