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