UF Service TripsCommon Clinical Issues

in Children

Rob Lawrence, MDPediatric Infectious

Diseases

OutlineObjectives

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

Approach to Diagnosisin

Resource Poor Settings• Ethics treat them as you would every patient,

including sensitivity to cultural issues.• Emphasize history and physical diagnosis to get to the

diagnosis.• Differential Diagnosis common/endemic >

urgent/critical=triage > treatable.• What are you set up / prepared to manage?• Empiric therapy lower threshold, need for follow-up.• Follow-up within their health system + education which

is culturally appropriate.

Growth, Development and Anemia• Growth: WHO Child Growth Standards

Multicentre Growth Ref. Study (MGRS)Stunting, wasting, malnutrition

• Development: Assessment ToolsObservation

• Anemia: Age, WHO standardsCorrelation with IQ, development and

association with intestinal parasites• Breastfeeding: WHO Recommendations

MGRS – standards, potentialAHRQ report #153 -07-E007 www.ahrq.gov Breastfeeding: More than just good nutrition. Lawrence RM Peds in Rev 2011;32;267.

Growth

Stunting • Height-for-age is less than

-2 SD (below the mean)

• Chronic undernutrition -retards linear

growth

Underweight• Weight-for-age is less than

-2 SD (below the mean)

• Inadequate nutrition over a shorter period of time

• Linear growth maintained• Head circumference growth

still OK (spares the brain)

Growth

Wasting• Weight-for-height less than

-2 SD (below the mean)• Acute malnutrition with

probable micronutrient deficiencies

• Increased risk of infections, diarrheal disease, death

• Odds ratio of mortality ~=2x mortality risk for children > -1 SD*

Severe Wasting• Weight-for-height less than

-3 SD (below the mean)

• Severe acute malnutrition• Odds ratio of mortality ~=

9x mortality risk for children > -1 SD*Black RE et al.

Lancet 2008, 371:243-60.Maternal and Child Undernutrition Study Group:

Kwashiorkor• Growth Failure• Wasting – muscles• Edema – abdomen,

scrotum, feet• Hair changes• Mental changes / activity• Dermatosis• Appetite diminished• Anemia • Fatty lliver

Principles of Treatment forSevere Malnutrition

Step Days 1-2 Days 3-7 Weeks 2-6

1. Hypoglycemia +++ + -

2. Hypothermia +++ + -

3. Dehydration +++ + -

4. Electrolytes ++ ++ ++

5. Infection ++ ++ +

6. Micronutrients ++ (no iron) ++ (no iron) ++ (with iron)

7. Cautious feeding +++ ++ -

8. Catch-up growth - - +++

9. Sensory stimulation ++ ++ ++

10. Prepare – follow-up - - +++

Ashworth A et al. Child Health Dialogue Issue 3 + 4, 199610 Steps – Guidelines for treatment of Severely Malnourished Children

Malnutrition

• Calories• Protein• Micronutrients

Vitamin A Iron

Iodine Zinc

Disease Control Priorities in Developing CountriesStunting, Wasting and Micronutrient Deficiency DisordersCaulfield LE, Richard SA et al. Chapter 28

Micronutrient DeficiencyDeficiency Consequences Foods Supplementation

Vitamin A Night blindnessInfection - mortality

Animal foods – fatLiver, milk, egg yolksDk green leafy vegetables, oil, Carotenoids, BM = breast milk

Capsules,Fortification of salt, flour, sugar, rice, butterBM + tri-vi-sol + iron

Iron AnemiaNeurologic impairmentImmune deficiency

Meat, beans, Breastmilk (BM)

Fortified – cereal, salt, sugarRx - 3 months*

Iodine Goiter, growth delayIntellectual impairment

Water, BM if it is in the H2O and mom has adequate Iodine

Water, salt, oil injection, BM – supplement mother and infant

Zinc Growth retardationImmune deficiency, skin disorders, cognitive function

Animal flesh, oysters, shellfish, BM

Flour, maize, rehydration salts, “sprinkles”, BM -OK

DevelopmentAGE “MILESTONES”6 MONTHS Watches faces, objects, smiles responsively, reaches / grasps

objects – both hands, turns to name / sounds, babbling, plays with fingers + hands to mouth , sits, decreased head lag

12 MONTHS Simple gestures –shake head “no”, waves bye, says “mama, dada”, pulls to stand – crawls – cruises, follows simple commands

2 YEARS Says words (50% are “understandable”), 2-4 words in a sentence, kicks a ball, walks without help, gets excited, points to things when named, follows simple instructions

3 YEARS Copies others, converses in 2-3 phrases/sentences, climbs stairs and other things, plays make-believe, shows affection without prompting, 75% of speech understandable

4 YEARS Hops and stands on 1 foot for 2 seconds, prefers to play with other children rather than alone, plays cooperatively, tells stories, draws a person with 2-4 body parts, 100% of speech understandable

AnemiaAGE, person, location Hb (hemoglobin) Hct (hematocrit)

Children (0.5 – 5 years) < 11 < 33

Children (5-12 years) < 11.5 < 34.5

Children (12-15 years) < 12 < 36

Non-pregnant women(> 15 years, sea level)

< 12 < 36

Non-pregnant women(> 15 years, @ altitude, e.g. Quito 7800 ft / 2800 m)

< 12.3 < 37

Screening: all children 1-6 years old, girls / women >12 years oldTreatment: 3-5 mg elemental iron/kg/day with juice / water between meals (not

with milk), 3 months – build iron stores without ongoing losses, diarrhea / blood in stool / parasites, menses, chronic undernourished due to lack of appropriate foods)

Abdominal Pain Diarrhea

Intestinal Parasites• Inter –related and overlapping diarrhea and

intestinal parasites can be the cause of pain• Abdominal pain has a broader, multi-organ differential• Diarrhea can be acute or chronic and has a broad

etiologic differential• Intestinal parasitic infections tend to be chronic with

non-specific symptoms

Abdominal Pain• Careful history and physical exam – associated

symptoms • Acute - look for a surgical condition• Chronic – consider peptic disorders, reflux, esophagitis,

gastritis, ulcers, H. pylori, parasites, recurrent abdominal pain, UTI, abdominal migraines, inflammatory bowel disease

• Red Flag Symptoms – weight loss, bilious emesis, intermittent diarrhea + constipation, bloody diarrhea, fever, arthritis/arthalgias, hepatosplenomegaly, dysphagia, respiratory symptoms

Diarrhea• Acute diarrhea – watery (volume), viruses rotavirus,

adenovirus, enteroviruses, food intolerance if < 24 hours, less commonly Salmonella, E. coli, Shigella, Cryptosporidium, Giardia, Campylobacter

• Chronic diarrhea (>14 days) – acute + malnutrition (Zn or Vit. A), or recurrent episodes, bacteria – E.coli (EAEC, EPEC), Shigella, Salmonella, Cryptosporidium, Cyclospora, Giardia – alternating with constipation +/- abdominal pain think parasites

• Acute bloody diarrhea – small frequent bloody stools, pain, tenesmus – Shigella, Campylobacter, Entamoeba histolytica, +antibiotics or hospitalization consider Clostridium difficile,

• Diagnosis: labs only for chronic diarrhea, or persistent bloody d.• Therapy: avoid antibiotics unless febrile, anti-diarrheal meds are

ineffective / not advised in children, ORT, nutrition, educationKeusch GT et al. Diarrh. Diseases. C 19 Dis Control Priorities in Dev Countries

ParasitesParasite Importance Diagnosis Therapy

Giardia +, water sources, persistent diarrhea, FTT

Copro exam of stool

Empiric Albendazole 10-15mg/kg QD x 5 daMetronidazole 15-30mg/kg ÷ Q8h x 5 daFurazolidone, Nitazoxanide

Amebiasis Non=-specific GI, Colitis, Ameboma, liver abscess

EIA stool, EIA blood, colonoscopy

Metronidazole 30-50mg/kg ÷ Q8h for 7-10 daysLuminal agent - paromomycin

Tapeworms (T. Solium/Saginata)

Asymptomatic, anorexia, abd. pain, FTT, Neurocysticersosis

Seen in stool, Praziquantal 5-10mg/kg x 1

Hookworms-N. americanus, Ancylstoma

skin – dermatitis / itch, non-specific GI, Fe, nutritional def.

Albendazole 400mg PO x 1 Mebendazole 100mg BID x 3 da

Pinworms Perianal itching, excoriation, rash

Exam, Tape test, stool,

Albendazole 100mg x 1 or 400mg PO x 1 if > 2 yrs.

Ascaris Abd. pain, nausea, diarrhea, GI obstruction, Loeffler’s Syn.

Copro exam Albendazole 200mg x 1 or 400mg PO x 1 if > 2 yrs.

Important Arthropod-borne Illness

Malaria - 2009 Dengue - 2010

WHO Reports

ComparisonDengue

• 50-100 million infections / yr• Incubation 3-14 days (4-7)• Asymptomatic – initial episodes, mild

febrile illness• Dengue Fever –fever -> 41o , bone,

headache,hematologic abnormalities, hyponatremia

• Dengue Hemorrhagic Fever / Shock –biphasic fever, thrombocytopenia, ↑ Hct, low albumin + Na, DIC, acidosis, CV collapse

• Severe disease = prior infection(s)• Mosquito protection!• Dx: clinical syndrome / endemic• Rx: supportive!!• Serotypes: DenV1-4

Malaria• Children 3-36 months, pregnancy• Incubation 12-35 days• Uncomplicated fever + non-

specific sxs• Complicated cerebral,

hypoglycemia, acidosis , renal / liver failure, anemia, ARDS, CV collapse

• Recrudescence, relapse, repeat• Prophylaxis• Dx; clinical, Giemsa stained smears,

parasite density• Rx: various drugs specific types,

Plasmodium (4)– falciparum, vivax, ovale, malariae

Antimalarial DrugsDrug Uncomplicate

dComplicated Prophylaxis Cost Available

in U.S.

Chlorquine + + $ (< 1) +

Amodiaquine + $ (-)

Quinine + + $$ +

Quinidine + $$$ >10 +

Mefloquine + + $$ +

Sulfadoxine-pyrimethamine

+ $ +

Atovaquone + + $$$ +

Artemethr- lumefantrine

+ $$ +

Clindamycin + + $$ +

Tetra – Doxycyc + + + $ +

Primaquine + hypnozoites prevent relapse $ +

Tuberculosis• Clinical TB Disease 1o

pulmonary, LN, other organs Cough, fever, weight loss, night sweats, malaise, hemoptysis

• Latent TB Infection[LTBI] Rarely addressed TST, CXR, No Sx

• BCG (Bacillus of Calmette-Guérin)Scars - deltoidProtection – meningitis, miliary TB Effect on TST – cutoffs, < 5yrs, >15 mm

• Multi-drug Resistant TB = MDR-TBPoor-compliance, mutationsCo-infection with HIV + TBInadequate infrastructure / Public Health / DOT

Tuberculosis

• Dx: clinical, CXR, smears, AFB, uncommonlyculture, DNA

• Rx: IsoniazidRifampin

(rifamycins) PyazinamideEthambutol2o line agentsDirectly

Observed Therapy (DOT)Public Health

BCG Vaccination PolicyA = Universal BCG vaccination B = BCG in the past, C = never gave BCG

BCG Scars

TST Reactions