Paediatric Conditions

Constipation

• On examination there is faecal soiling of under wear and persistent faecal odour. Abdomen is often distended and tympanic to percussion. Faecal masses palpable above pubis and in left colon, rarely entire colon is filled with firm mass on rectal examination, hard stool is palpable in ampulla.

• Dietary modification: Ensure adequate fluid intake in diet. In infants, breast milk should continue as it is less likely to be constipating than cow’s milk, can add extra sugar in cow’s milk if child is not breast-fed.
• Add fibre by cereals (wheat bran, oat, corn), pulses, vegetables, salads and fruits and isabgol.
• Behavioural modification
  - Toilet training to achieve regular evacuation. Child is instructed to use bathroom after break fast or dinner, to take advantage of meal stimulated increase in colonic motility.
  - Maintain calendar to record stooling.
  - Positive reinforcement (reward/appreciation) for successful toileting (no punishment for failure)

1. Agarol or Lactulose in infants 2.5-10 ml/day; children 40-90 ml/day in in 3-4 divided doses.
   Or
   Mineral oil (Liquid paraffin) 5-15 ml/kg/day
   Or
   Milk of Magnesia 0.5-3 ml/kg/day. Dose is titrated to produce at least one stool/day.
   Medical management has to be with different group of laxatives added serially to maximal doses and maintained for a considerable length of time (3-6 months) and then tapered gradually. Commonest cause of failure is short term treatment and suboptimal doses.
2. Enemas may be used in severe cases where sufficient trial of medical therapy has failed

• The parents should be empowered to titrate the medication against the child’s stools.
• Importance of dietary modifications should be explained.
• Treatment should not be abandoned early after recovery.
• Bowel training should have only positive reinforcements. Negative reinforcement should be avoided at all costs.

1. Management of Constipation and Encopresis in Infants and Children. In: Gastroenterology Clinics of North America, 1994, 23: 621- 636.
2. Encopresis and Constipation in Children. In: Paediatric Clinics of North America, 1988; 35: 257- 280.
3. Diarrhoea & Constipation. In: Harrison’s Principles of Internal Medicine. Braunwald E, Fauci AS, Kasper DL et al (eds), 15th Edition, 2000, McGraw Hill Company Inc., New York, pp 241-250.
4. Major Symptoms and Signs of Digestive Tract Disorders. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman et al (eds), 16th Edition, 1999, pp 1102-1108.
5. Appraoch to Patient with Constipation. In: Text book of Gastroenterology, Yamada T, Alpers PH, Laine L et al (eds), 1999, Lippincott Williams and Wilkins, Philadelphia, pp 910-926.
6. Acquired Constipation in Children. Treatment Protocol. In: Recent Advances in Paediatric Clinical Gastroenterology, BR Thapa (ed), 2001, Relume Printec, Chandigarh, pp 170-180.l .

Thrush (Oral Candidiasis)

• Emphasize on bottle hygiene, care/hygiene of the nipple and treatment of vaginal candidiasis in expectant mother.

1. Treatment of Oropharyngeal Candidiasis in Neonates. In: Review and Appraisal. Paediatric Inf. Dis. J, 1997-16/9 , pp 885- 894.
2. Mycotic Infection . In: Text Book of Paediatrics, Martin Wesse & Stephne C. Aronoff (ed), pp 933-934.

Asthma

1. Oxygen inhalation at a rate of 4 L/minute by oxygen hood/nasal catheter/face mask.
2. Inhaled Salbutamol/Terbutaline by MDI with spacer with/without face mask 1-2 puffs ever 2-4 minutes up to 10 puffs and repeat every 20-30 minutes.
   Or
   Nebulized Salbutamol 0.15 mg/kg in 3 ml saline every 20-30 minutes.
   Or
   Inj. Terbutaline 10 mg/kg SC or Inj. Adrenaline (1:1000) 0.01 ml/kg SC (upto 0.03 ml) every 20-30 minutes with a total of 2-3 doses.
3. Tab. Prednisolone 1 mg/kg stat. Assess the child after 60-90 minutes.
   Good response: continue inhaled salbutamol/ terbutaline every 2-4 hours and gradually decrease the frequency of administration with monitoring.
   The patient can be sent home when shows good response, not requiring oxygen inhalation, not having difficulty in speech or feeding and getting inhaled medication 4-6 hourly. The child can be sent home on inhaled Salbutamol/Terbutaline, oral Prednisolone for 3-5 days and call after 5-7 days for reassessment.

1. Continue oxygen inhalation as above.
2. Continue Salbutamol inhalation every 20-30 minutes as above.
3. Add Ipratropium inhalation 250 mcg with Salbutamol every 20-30 minutes.
4. Give another dose of oral Prednisolone.
   Get an X-ray chest and rule out infection, pneumothorax or collapse of segments or lobes of lung and manage accordingly. Do arterial blood gas analysis and serum electrolytes for detection of acidosis and hypokalaemia and manage accordingly and reassess after 60 minutes.
   Good response: continue oxygen, Beta agonists, Ipratropium and oral Steroids for 5-7 days. Decrease the frequency of Salbutamol inhalation, stop oxygen inhalation by monitoring the patient’s clinical features and oxygen saturation. Discharge the patient when there is no respiratory distress, not requiring oxygen inhalation and getting salbutamol 4-6 hourly. Call the patient for reassessment after 5-7 days for consideration of maintenance treatment.
   Poor response: Inj. Theophylline 5 mg/kg diluted slow infusion and than 0.8-1.2 mg/kg/hr as infusion. Inj. Magnesium sulphate 50 mg/kg in 50 ml 5% dextrose over 30 minutes may also be given at this stage. Continue as above
   Reassess if good response: Continue Salbutamol and Ipratropium
   inhalation, Prednisolone, and Beta agonists. Reduce frequency of inhaled medication with monitoring. Discharge the patient when completely well, on inhaled Salbutamol, oral Steroids and call after 5-7 days for reassessment.
   Poor response: Transfer to a paediatric intensive care unit if facility exists or refer to a higher center.

1. Oxygen inhalation 4 L/min to maintain SpO2 >90%.
2. Inj. Terbutaline 10 mcg/kg subcutaneously or IV.
3. Inhaled Salbutamol/Terbutaline preferably by nebulizer (as discussed above).
4. Ipratropium Bromide 250 mcg by nebulizer with Salbutamol.
5. Inj. Hydrocortisone 10 mg/kg IV.
6. Inj. Aminophylline 5 mg/kg bolus slowly followed by 0.8-1.2 mg/kg/hour slow infusion (If patient has received theophylline preparation in last 72 hours; reduce bolus dose to 2.5 mg/kg).
7. Inj. Magnesium sulphate 50 mg/kg in 50 ml 5% dextrose as slow infusion over 30 minutes.

• Antibiotics are required only if there is a consolidation, high grade fever or polymorphonuclear leucocytosis.
• Mucolytics and cough syrups are not helpful.
• Sedation should be avoided in acute asthma.
• Newer antihistaminics may be used if associated allergic rhinitis is there.

• Doses prescribed in Table 2 are for Budenoside and Beclomethasone, if Fluticasone is used at only half of the prescribed dose may be necessary.
• In a patient with symptomatic moderate to severe disease begin with a higher dose. It is preferrable to add long acting bronchodilator (Salmeterol, Formetarol) initially because of quicker symptomatic relief and steroid sparing effect.

• Children below 4 years of age: Metered dose inhaler (MDI) with spacer with facemask
• For children above 4 years of age: MDI with spacer
• For children above 12 years of age MDI may be used directly. However use of spacer improves drug deposition in airways.

1. Identify acute exacerbation by increase in cough, wheeze and breathlessness.
2. Measure PEFR (if feasible) if decreased by 15% from the baseline.
   Administer Salbutamol by MDI with spacer with or without face mask, one puff at a time, repeated every 2-4 minutes up to a maximum of 10-20 puffs with monitoring of symptoms.
   If symptoms are relieved and PEFR is increased at the end of inhalation, the child can be continued on Salbutamol/Terbutaline every 4-6 hours and a visit to treating physician should be planned.
   If there is no improvement or partial improvement or there are symptoms of life threatening attack (severe distress, difficulty in speech, feeding, cyanosis, exhaustion) at any time, the child should be immediately transferred to a hospital and during transportation continue inhaled Salbutamol/Terbutaline and give a dose of prednisolone (1-2 mg/kg).

• Explain the nature and pathogenesis of asthma in simple language
• Emphasize that there is a wide spectrum of severity of asthma and that most children can lead active and normal life
• Ask to maintain a record of daily symptoms such as cough, coryza, wheeze and breathlessness. A record of sleep disturbances, absence from school due to illness and medication required to keep the child symptom free is advised.
• Environmental control to avoid precipitating factors is equally important.
• Parents should avoid dusting (wet mopping is preferred) when children are around.
• Avoid using carpets, stuffed toys, open bookshelves, smoking and chemical sprays in the house. Mosquito nets should be preferred over repellents.
• Food with chemicals like preservatives/colouring agents should be avoided.
• Inhalation technique: It is best to use MDI with spacers, however, if low dose steroids are being given then dry powder inhaler can also be used. MDI must be shaken well before inhalation. It is then attached to spacer (commercial/indiginous made from plastic bottle) and child is asked to inhale 3-4 times slowly and deeply just when the drug is released by activation of MDI.
• Parents must be advised to check the cannister every few days dipping it in a tumbler full of water. An empty cannister floats.

1. Consensus Guidelines on Management of Childhood Asthma in India. Indian Paediatrics 1999, 36, 157-165.
2. Asthma. In: A Followup Statement from an International Paediatric Asthma Consensus Group. Arch Dis Child 1992, 67:240-48.
3. National Heart Lung and Blood Institute and World Health Organization. Global Initiative for Asthma. National Institute of Health, Bethesda, 1995 Publication No. 95-3659.
4. National Heart Lung and Blood Institute. Expert panel report 2. Guideline for the Diagnosis and Management of Asthma. National Institute of Health, Bethesda HD, 1997 Publication No. 97-4051.
5. The British Guidelines on Asthma Management: Review and Position Statement. Thorax 1997, 52:S1-S21.

Wheezy Child

Wheezing is a clinical symptom present in asthma and other illnesses including bronchiolitis and other viral infection, foreign body inhalation, tuberculosis, pneumonia, cystic fibrosis, immune deficiency, bronchomalacia, hypersensitivity pneumonia and conditions compressing airways. Wheezing during infancy could be due to viral infections. Absence of family history and personal history of atopy with gradual decrease in frequency of episodes is seen in many transient wheezers who grow out of their wheezing episodes. Wheezing in asthma is recurrent, gets worse in night and after exercise, seasonal and may be associated with other allergic illnesses like atopic dermatitis, allergic rhinitis etc. Clinical features suggestive of other cause of wheezing are: neonatal onset, associated with difficulty in feeding, choking or vomiting, localized findings in chest or abnormality in cardiovascular system.

Pneumonia

• Nasal block to be treated with saline nasal drops as and when required, especially before feeds.
• Ginger, honey, tulsi with warm beverages can be used as home remedies for cough.
• Patients with respiratory distress to be nursed in semi reclined posture at angle of about 30º.
• Young infants should be nursed in comfortable position preferably in mother’s lap.
• Breast feeding and small frequent feeds to be continued in children who do not have severe or very severe pneumonia.

Pharmacological

Fever to be treated as in section on fever. Treatment is initiated according to the severity.

a) Pneumonia
Patients with age more than 2 months and with absence of features of severe/very severe pneumonia can be treated at home.
Tab./Syp. Amoxycillin 20-40 mg/kg/day in 3 divided doses for 5-7 days.
Or
Tab./Syp. Cephalexin 20-40 mg/kg/day in 3 divided doses for 5-7 days.
Or
Tab./Syp. Cotrimoxazole (TMP) 6-8 mg/kg/day in 2 divided doses for 5-7 days.
b) Severe pneumonia and very severe pneumonia age <2 months
Patient should be hospitalized
1. Oxygen inhalation 4 L/min
2. IV fluids to maintain normal hydration.
Inj. Cefotaxime 100 mg/kg/day in 3 divided doses for 7-10 days.
Or
Inj. Cefuroxime 100 mg/kg/day in 2 divided dose for 7-10 days
Or
Inj. Ampicillin 100 mg/kg/day in 3 divided doses Plus
Inj. Gentamicin 7.5 mg/kg/day in 2-3 divided doses for 7-10 days.
c) Severe pneumonia and very severe pneumonia with age >2months
Inj. Chloramphenicol 100 mg/kg/day in 3-4 divided doses for 7-10 days.
Or
Inj. Ampicillin 100 mg/kg/day in 3-4 divided doses for 7-10 days. (preferred in children >3 years)
High risk patients in category (c) i.e. post measles, with congenital heart disease and severe malnutrition etc may be given Amoxycillin + Clavulanic acid, Cefotaxime/Cefuraxime as initial therapy.
Children who deteriorate rapidly, develop empyema/pneumothorax or have skin lesions suggestive of Staphylococcal infection – should be treated with Inj. Cloxacillin 200 mg/kg/day in 3-4 divided doses + Inj. Gentamicin 7.5 mg/kg/day in 2-3 divided doses.

Follow up and monitoring

Children with mild pneumonia are reassessed at 48 hours or earlier if child deteriorates. If child shows improvement same treatment is continued for 5-7 days. If deteriorates patient is hospitalised and treated as severe/very severe pneumonia. Children who are hospitalised (severe and very severe pneumonia) are monitored more frequently. Children with severe/very severe pneumonia (age >2 months) on deterioration can be treated with cefotaxime/cefuroxime in the doses given in (b).

Patient /Parent education

• Explain the signs of pneumonia i.e., rapid respiratory rate, chest indrawing, difficulty in feeding etc.
• Explain the danger signals in a child suffering from pneumonia.

References

1. Epidemiology of Acute Respiratory Tract Infection in Children of Developing Countries, Rev Infect Dis 1990; 13 (suppl) 60: S 454-67.
2. The WHO Young Infant Study Group, Bacterial Etiology of Serious Infections in Young Infants in Developing Countries: Results of Multicentre Study, Paediatric Inf. Dis. J, 1999, 18 (suppl): S17-S22.
3. Technical Bases of WHO Recommendation on the Management of Pneumonia in Children at First Level Health Facility, 1991, WHO/ARI/91.20, Geneva, World Health Organization.
4. Etiology of Community Acquired Pneumonia in 254 Hospitalized Children, Paediatric Inf. Dis. J, 2000, 19: 293-98.
5. WHO Guideline on Detecting Pneumonia in Children, 1991, Lancet, 338: 1453-60.
6. Diagnosis and Management of Pneumonia in Children. Paediatric Inf. Dis. J, 2000; 19: 924-28.

Acute Bronchiolitis

• For associated nasal block normal saline drops in both nostrils as and when required, specially before feeds, and use of home remedies (ginger, honey, tulsi) for control of cough and plenty of liquids orally.
• For hospitalised patients elevation at 30-40 degree and neck slightly extended.
• To be nursed in comfortable environment.

Pharmacological

Treatment of mild disease (Ambulatory treatment at home)
No antibiotics.
Syp. Paracetamol 10-15 mg/kg 4-6 hourly for fever (for details see section on fever).
If patient shows overall improvement with no evidence of chest indrawing, cyanosis, difficulty in feeding continue treatment as above. If there is partial improvement patient should be called again after 2 days or earlier if patient deteriorates for reassessment.
Hospitalize immediately if any of the following develop:
Chest indrawing, poor feeding, cyanosis, altered sensorium and convulsions and managed as severe disease.
If there is no improvement or deterioration at any time during the illness, the patient should be managed as severe disease.
Treatment of the severe disease (Needs hospitalization for management)

1. Oxygen administration by oxygen hood or nasal catheter and intravenous fluids if child is not able to feed.
2. Adrenaline inhalation (Injectable form) 0.3 mg/kg by nebulizer after dissolving the solution in 3 ml saline; can be repeated every 4-6 hourly as required.
   (No role of antibiotics, steroids, ribavirine inhalation in uncomplicated patients).
3. If adrenaline not available Salbutamol inhalation (0.15 mg/kg dissolved in 3 ml soln) may be tried and continued if response observed.
4. Syp. Paracetamol 10-15 mg/kg/dose may be given 4-6 hourly.
5. Do not use sedatives.
   Monitor improvement in respiratory rate, lower chest indrawing, difficulty in feeding, excessive crying, cyanosis and oxygen saturation, if available, every 4-6 hours till there is significant improvement. If does not improve/deteriorate look for underlying heart disease i.e., myocarditis/congenital heart disease and get an X-ray chest and look for massive collapse of lung/infection/pneumothorax etc. and manage accordingly.

Patient education

• Mother should be educated about the signs of pneumonia i.e., rapid respiratory rate, chest indrawing, difficulty in feeding.
• Mother should be educated about identification of danger signals in a child suffering from pneumonia and report immediately to the health care facility.

References

1. Bronchodilators for Bronchiolitis, 2, CD001266, 2000 Cochrane Database Syst Rev.
2. Prednisolone Treatment of Respiratory Syncytial Virus Infection: A Randomized Controlled Trial of 147 infants. Paediatrics, 1999, pp 104, 77.
3. Randomized Placebo-Controlled Trial of Nebulized Corticosteroids in Acute Respiratory Syncytial Virus Bronchiolitis. J Accid Emerg Med,17, 2000, pp 369.
4. Ventilated Respiratory Syncytial Virus Bronchiolitis. A Randomized Placebo Controlled Trial. Am J Respir Crit Care Med, 1999, 160, pp 829-34.

Primary Nocturnal Enuresis

• Rule out organic causes. Restrict fluid intake in the evening.
• Bladder exercises:
  i) hold urine as long as possible during the day.
  ii) practice repeated starting and stopping the stream at the toilet bowl.
• Practice getting up from bed and going to the bathroom at bedtime before sleep.

Pharmacological

Indicated only in children > 6 years where sufficient trial of nonpharmacological management has failed with following:

• Tab. Imipramine: 6-8 year (25 mg), 9-12 year (50 mg), >12 year (75 mg) once a day at bedtime. Success rate 30-60%, relapse rate 90%
  Or
  Desmopressin acetate (nasal spray, 10 mcg per spray): Start with 10 mcg given at bedtime daily and increase gradually by 10 mcg/per week to a maximum of 40 mcg per day. If effective, it should be used or 3-6 months. Success rate is 40-60%, relapse rate 90%.
  Or
  Tab. Desmopressin 0.1-0.5 mg at bedtime.
  Refer the patient to a higher centre if organic cause is suspected or when diagnosis is in doubt.
  

Parent education

• Reassure the parents that condition is self-limiting.
• Ask the parents to maintain a diary record of dry nights; reward the child for such nights. Avoid punitive measures.

References

1. Current Paediatric Diagnosis and Treatment. Hay WW, Hayward AR, Levin MJ,et al (eds), 15th Edition, 2001, Lange Medical Books, New York, pp 175-176.
2. Nocturnal Enuresis. In: Evidence Based Paediatrics and Child Health, Meyer VA, Elliott EJ, Davis RL, et al (eds), 2000, BMJ Books, London, pp 313-317.
3. Enuresis. In: Essence of Office Practice, Stockman JA, Lohr JA (eds), 2001, WB Saunders, Philadelphia, pp 127.

Breath Holding Spells

• Avoid precipitating factors such as exhaustion, hunger, or injury. Do not give toys or tasks beyond the child’s abilities and try to distract.
• Avoid excessive rules and restrictions. Try to remove unnecessary frustrations.

1. Breath Holding Spell. In: Essence of Office Practice, Stockman JA, Lohr JA. Philadelphia (eds), 2001, WB Saunders, pp 53.
2. Breath Holding Spell. In: Current Paediatric Diagnosis and Treatment, Hay WW, Hayward AR, Levin MJ et al (eds), 15th Edition, 2001, New York, Lange Medical Books, pp 80.
3. Breath Holding Spells, Paediatric Neurol,14, 1996, pp 91.

PICA

• Pica below two years does not need any intervention.
• Children with pica are at increased risk of lead poisoning, iron deficiency,bezoars, and parasitic infections. They should be investigated for these problems and if present, treated suitably.
• Education, guidance and counseling of the family.
• The child has to be kept occupied in other tasks and provided with the environmental stimulation.

References

Vegetative Disorders. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th Edition, 1999, pp 72.

Protein Energy Malnutrition (PEM)

1. Mild and moderately under-nourished children are best treated in their own home surroundings. Domiciliary treatment of malnourished children by their mother is economical, offers in-built advantage of practical health education, and is associated with minimal recurrence risk.

1. Protein Energy Malnutrition. In: Ghai’s Essential Paediatrics, Ghai OP, Gupta P, Paul VK (eds), 5th Edition, 2000, New Delhi, Interprint, pp 65-77.
2. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers,1999, WHO, Geneva.
3. Management of The Child With a Serious Infection or Severe Malnutrition, 2000, WHO, Geneva.

Anaemia

1. Deficiency of one or more of haematopoietic nutrients i.e. iron, folic acid, and vitamin B12. Deficiency of other nutrients such as copper, protein etc. is uncommon.
2. Bone Marrow infiltration due to abnormal cells as in acute and chronic leukaemia, disseminated malignant diseases, myelofibrosis etc.
3. Bone marrow aplasia -congenital and acquired aplastic anaemia (severe and moderately severe) and pure red cells aplasia such as Diamond – Blackfan syndrome, transient erythroblastopenia of childhood.

2) Anaemia due to increased RBC destruction i.e., haemolytic anaemia. Commonest hemolytic anaemia seen in this part of the country is b thalassaemia major. Others include sickle cell disease, hereditary spherocytosis, G6PD deficiency, immune hemolytic anaemia etc.

3) Anaemia due to excessive blood loss -usually in such cases, the site of bleeding is obvious e.g. massive esophageal variceal bleeding, rectal polyps etc. In cases like ankylostomiasis, Meckel diverticulum etc. there may be only occult bleed.

Clinical approach in a child with anaemia- Careful history and physical examination provide useful clues towards the likely cause of anaemia, thereby guiding the most appropriate laboratory tests required to avoid unnecessary expenses in diagnosis, e.g.

1. Nutritional iron deficiency anaemia (IDA) is uncommon below 6 months of age in term born child with normal birth weight.
2. Most thalassemics are normal at birth and usually start becoming anaemic between 6 -18 months of age.
3. Constitutional aplastic anaemia (Fanconi pancytopenia) presents between 5-10 years, whereas congenital pure red cell aplasia can manifest in first few months.
4. Megaloblastic anaemia occurs in infants and toddlers preschool children with prolonged exclusive breast feeding by undernourished mothers.
5. Presence of splenomegaly and haepatomegaly suggests the diagnosis of either haemolytic anaemia or leukaemias (usually there is associated lymphadenopathy) or anaemia of chronic infection/inflammation.
6. Presence of petechial and/or purpuric spots is suggestive of concomitant thrombocytopenia and points towards the diagnosis of acute leukaemias, aplastic anaemia or megaloblastic anaemia.

Investigations

Initial investigations to be carried out in cases of anaemia – estimation of Hb %. TLC, DLC and platelet count, examination of peripheral blood smear for RBC size and shapes, anisopoikilocytosis, presence of immature cells and haemoparasites, reticulocyte count. Currently, most of the laboratories use electronic cell counters for haematological investigations which give additional useful information such as MCV, MCH, MCHC etc.

Following important information can be gathered from the above investigations:

1. Type of anaemia -on the basis of cell size -such as microcytic (MCV<80fl), normocytic and macrocytic (MCV>90fl) -and on the basis of Hb content i.e. hypochromic or normochromic.
2. Associated thrombocytopenia and/ or neutropenia (bicytopenia or pancytopenia) is suggestive of aplastic anaemia, megaloblastic anaemia, or bone marrow infiltration due to leukaemia, etc.
3. Increased, normal or decreased reticulocyte count is suggestive whether anaemia is due to decreased production or increased destruction of RBCs.
   Following section describes the differential diagnosis of cases of anaemia according to preliminary investigations results

a. Microcytic hypochromic anaemia – two important causes are

1. IDA – reticulocyte count is normal or mildly elevated.
2. Thalassaemia major – reticulocyte count is usually 4-6%. Peripheral smear also shows target cells and numerous nucleated RBCs. Elevated foetal haemoglobin (HbF) on blood electrophoresis confirms the diagnosis. Lead poisoning and pyridoxine responsive anaemia, sideroblastic anaemia and copper deficiency are rare.

b. Macrocytic normochromic anaemia

1. Megaloblastic anaemia of B12 and folate deficiency are the commonest and may have associated neutropenia and/or thrombocytopenia, Reticulocyte count is usually low. Bone marrow examination reveals megaloblastic changes.
2. Other causes of macrocytic anaemia are liver diseases, hypothyroidism, thiamine deficiency and some inborn errors of metabolism.

c. Normocytic normochromic anaemia – This group comprises a large number of causes -

1. Congenital or acquired aplastic anaemia -usually have bicytopenia or pancytopenia and decreased reticulocyte count. Bone marrow aspiration or biopsy is confirmatory.
2. Bone marrow infiltration such as leukeamia and other neoplasms, storage disorders, myelofibrosis etc. Diagnosis is confirmed by bone marrow examination.
3. Hemolytic anaemia -such as immune haemolysis, hereditary spherocytosis, G6PD deficiency etc. Reticulocyte count is increased.
4. Anaemia resulting from acute blood loss.

Hyponatraemia

1. If fluid overload, renal failure, or SIADH is present, restrict fluid intake to 2/3 of the normal maintenance. If dehydration is present, expand ECF volume by giving isonatremic fluids intravenously depending on the degree of dehydration.
2. Sodium. Acute symptomatic hyponatraemia is treated with administration of 3% sodium chloride 1-2 ml/kg/h till symptoms resolve.Chronic hyponatraemia should be corrected over a period of 48 hours.
   The deficit is calculated as follows:
   Sodium deficit = [desired Na+ - present Na+] x weight x 0.6

Hypokalaemia

• Identify and treat the underlying cause.
• Correct the deficit with potassium supplements @ 40 mEq/L of fluids.
  The amount of fluid is dictated by the hydration status of the child. Potassium chloride may be given orally (15 ml = 20 mEq). Intravenous correction with
  KCl (1 ml = 2 mEq) is required when patient is unable to take orally, serum potassium is < 2.5 mEq/L, has respiratory paralysis, or in presence of arrhythmia.
• Correct the potassium deficit over a period of 24 hours.
• Potassium rich foods such as banana or fruit juice may be advised on long term basis, specially in undernourished children.

Hypernatraemia

1. excessive administration of sodium (accidental salt administration in ORS),
2. inadequate water intake or
3. excessive water losses. Symptoms are non specific or relate to CNS such as altered sensorium or convulsions.

• Identify and treat the underlying cause.
• Replace water deficit as assessed by degree of dehydration over a period of 48 hours with a solution containing 40 mEq/L of sodium. Over rapid correction may lead to cerebral oedema. (CAUTION: Sodium free solutions are never used except when hypernatraemia is acute i.e. onset within few hours).
• Serum sodium >180 mEq/L may require urgent dialysis.

Hyperkalaemia

1. Mild hyperkalaemia: Serum K+ 5.5 to 6.0 mEq/L is managed by stopping the potassium intake and offending drugs such as potassium sparing diuretics, correction of acidosis and intravascular volume.
2. Moderate hyperkalaemia (serum K+ 6 to 8 mEq/L or peaked T waves) is managed by administering a glucose insulin infusion (0.5 g/kg glucose with 0.3 U regular insulin/g glucose, over 2 hours) and/or a sodium bicarbonate infusion (2 mEq/kg over 5-10 min), in addition to the measures already mentioned. Can be repeated 4-6 hourly.
3. Patients with severe hyperkalaemia (serum K+ >8 mEq/L or ECG changes apart from tall T waves) should be urgently administered intravenous 10% calcium gluconate 0.5 ml/kg over 5-10 minutes. This immediately reverses the cardiac effects of hyperkalaemia. This should be followed up with the measures as for moderate hyperkalaemia. Intravenous Salbutamol (4 mcg/kg in 5 ml water) or nebulised salbutamol (2.5-5.0 mg) given over 15-20 minutes also acts rapidly to lower serum K+. Dialysis has to be done in case the hyperkalaemia is refractory to therapy as in renal failure.
4. Monitoring of the therapy should be done with ECG and serum potassium levels.

>> See also Fluid & electrolyte imbalance in chapter 2
>> See also Fluid & electrolyte imbalance in chapter 19

References

1. Fluid and Electrolytes. In: Paediatric Emergency Medicine. American College of Emergency Physicians, Strange GR, Ahrena W, Lelyveld S et al (eds), 1996, McGraw Hill Company Inc., New York, pp 339.
2. Maintenance of Normal Fluids. In: Manual of Paediatric Therapeutics,1990, Boston, Little Brown and Co. pp 189-197.
3. Fluid and Electrolyte Therapy. In: Current Paediatric Therapy.1999, Philadelphia, WB Saunders, pp 860-869.

Fluid And Electrolytes

1. Correction of preexisting deficits; The losses, via renal or extrarenal route, should be estimated and corrected as soon as possible; for example, rehydration therapy for diarrheal dehydration.
2. Provision of maintenance requirements for normal metabolism.
3. Correction of ongoing losses. These may occur via the gastrointestinal tract through losses (as in diarrhea, vomiting etc.) or removal (suction, aspiration etc.). Replacement of such losses should be similar in type and amount to the fluid being lost.
   Out of these three phases, we shall discuss the maintenance requirements here. Correction of preexisting deficits and correction of ongoing losses shall be discussed, wherever relevant (See Section on diarrhoea – diarrhoea & in children – and dehydration).

Maintenance requirements in children

A guideline for estimating daily fluid and electrolytes requirement in a normal child under normal conditions is: Water-100 ml/100 Kcal/day;
Sodium-1-3 mEq/100 Kcal/day; Potassium-1-2 mEq/100 Kcal/day. Hence the fluid requirement based on caloric requirement for different weight groups can be calculated as follows:

Maintenance fluid requirement replaces water loss through skin (2/3 of losses), GIT, respiration, and urine. These losses are affected by ambient humidity, clothing, body temperature, respiratory rate, and age of the child. Situation specific adjustments are necessary when calculating maintenance fluids.
Refer to the section on newborn care for guidelines on fluid therapy in neonates and those weighing <3.0 kg.
The most commonly employed intravenous maintenance fluid employed in children is N/5 (0.18%) sodium chloride in 5% glucose + potassium chloride 20 mEq/Liter. Commercially it is available as Isolyte P, Kidral etc. C

Maintenance requirements in newborns

The table below provides the normal fluid electrolyte requirements in newborn babies.

• From day 3 onwards, fluid containing glucose-electrolyte mixture can be provided using commercially available paediatric maintenance intravenous solutions.
• The fluid and electrolyte requirements from day 7-28 remains the same.
  However, in babies <1500 g the fluid requirement after day 7 need to be increased by 10-20 ml/kg/day till a maximum of 150 ml/kg/day.

Conditions that increase fluid requirement

• Fever: for every 1ºC increase over 37.5ºC, the fluid requirement increases by 10 ml/kg/day.
• Phototherapy: this increases fluid requirement by 10-20 ml/kg/day.

Conditions that decrease fluid requirement

• Congestive cardiac failure: Fluid requirements are reduced to 2/3 of the normal need for that age.
• Renal failure: In cases of decreased urinary output, the fluid regimen is 400 ml/m2/day for insensible water losses plus urinary output over the day. Potassium should be added with caution or omitted in suspected cases of acute renal failure.

Immunization Schedule

1. Different vaccines can be given at the same time.
2. A gap of 1 month is recommended between 2 live vaccines if not given together.
3. Generally there is no need to restart immunization if the gap between immunization doses is more than the recommended interval.
4. DPT, DT, TT, Typhoid (Vi) and Hepatitis B vaccines should not be frozen.
5. Vaccines are generally stored between + 2°C and +8°C.

References

1. National Child Survival and Safe Motherhood Programme. Maternal and Child Health Division, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India, 1994.
2. Resuscitation in the Delivery Room. In: Avery’s Diseases of the Newborn. Taeusch HW, Ballard RA(eds), 7th Edition, 1998, WB Saunders Co., Philadelphia, pp 319-333.

Management Of Common Clinical Problems In Newborns

Regurgitation of feeds and vomiting: unlike vomiting, non-projectile expulsion of stomach contents without force (regurgitation) is normal and simply needs advice regarding feeding technique.

Bowel disorders: no medication should be prescribed for passage of stools after each feed (exaggerated gastrocolic reflex) as this is normal in some babies. From 3rd to 14 days many exclusively breast-fed babies pass loose stools (10-15 times/day) without illness/dehydration. These are transitional stools and require no medication.

Delayed passage of urine: non-passage of urine by 48 hours after birth may suggest urinary tract anomalies. Such babies need to be investigated. Crying before passing urine is normal.

Jitteriness: is abnormal only when it is excessive or persists even during feeding and then it may suggest hypoglycaemia or hypocalcaemia.

Dehydration fever: transitory moderate fever (up to 38.5oC) usually during the second or third day of life in summer months in an active baby, who sucks well, is normal and responds to lowering the environmental temperature.

Excessive crying: most baby cry when either they are hungry or are having discomfort such as due to full bladder before passing urine, wet napkin, nose block etc. Excessive inconsolable crying or high-pitched crying is indicative of meningitis or any other painful inflammatory conditions.

Umbilical sepsis: if there is pus discharge not extending to periumbilical skin, apply 10% Gentian violet or povidone iodine locally twice a day. However, if there is periumbilical erythema administer syrup erythromycin 40 mg/kg/day in 3-4 divided doses. If the newborn has any other high risk factor, refer to a higher centre.

Umbilical granuloma: a red flesh-like nodule at the base of umbilical cord can be managed by cautery with silver nitrate or application of common salt for 3 to 4 days.

Engorgement of breasts in both sexes and vaginal bleeding after 4 days of birth is normal.

Tongue-tie: rarely requires surgical intervention.

Neonatal Jaundice

1. Cord of 10 g/dl or less.
2. Cord bilirubin of 5 mg/dl or more.
3. Unconjugated serum bilirubin of more than 10 mg/dl within 24 hours
   or rate of rise of more than 0.5 mg/dl/hour.

b. In babies with jaundice due to other causes

1. Unconjugated serum bilirubin of 20 mg/dl or more in term baby.
2. In preterm babies, serum bilirubin of more than 1.0 mg/100 g weight of the infant (i.e. 10 mg/dl for 1000 g and 15 mg/dl for 1500 g and so on).
3. In the presence of asphyxia, respiratory distress, sepsis, hypothermia, exchange is performed at about 2 mg/dl lower serum bilirubin level than is otherwise indicated.

Low Birth Weight Babies

1. Keep the LBW babies warm:
   Room temperature should be kept between 28-30oC. Following methods may be used:
   · Maternal-baby skin to skin contact (Kangaroo mother care). Place the naked baby between the mother’s breast. Wrap baby and mother with a shawl. Cover the baby’s head with a cap.
   · Proper clothing – cap, woollen sweaters, socks and mittens.
   · Blankets.
   · Overhead radiant warmer.
   · Incubator.

2. Nutrition-Guidelines to provide fluids and nutrients to LBW babies.

   Age	Category of Neonates
   Birth weight Gestation	<1200 g <30 weeks	1200-1800 g 30-34 weeks	>1800 g> 34 weeks
   Initial	Intravenous fluids (60 ml/kg/day)with feed	Gavage (60 ml/kg/day)	Breast feeding If unsatisfactory,give katori/spoonfeeds
   After 1-3 days	Gavage (15-30 ml/kg/d), increase by15-30 ml/kg/day to a maximum of 180 ml/kg/day of expressedbreast milk	Katori/spoon Maximum of150-180 ml/kg/d	Breast
   Later (2-4 weeks)	Katori/spoon(150-180 ml/kg/day)	Breast	Breast
   After some more time (4-6 weeks)	Breast	Breast	Breast

3. Vitamin K 1.0 mg IM at birth.
4. Vitamin A 1000 IU orally daily – from 1 week age onwards.
5. Vitamin D 400 IU orally daily – from 2 week age onwards.
6. Iron 2 mg/kg/day orally daily – from 6 weeks age onwards.

7. Vitamin E, calcium and phosphorus supplementation in very LBW (<1500 g, <32 week gestation).

   Early detection of sickness by periodic evaluation – Referral to higher centre in the presence of any one or more of the following signs: Lethargy, refusal to feed, hypothermia, respiratory distress, grunt, apnoea, abnormal weight gain pattern, jaundice over soles and palms, abdominal distension, feed intolerance, cyanosis, pallor, sclerema, seizures and bleeding.