Pediatric Annotations # 3

1. In Bacterial meningitis (BM), role of dexamethasone (DXM):

a] Adjunctive therapy with DXM should be considered in selected cases of BM in infants and children. NOT recommended for neonates.

b] DXM has reduced hearing impairment in kids with H influenzae type b meningitis when given with or before starting antimicrobial therapy.

However the same benefit has not been seen with Pneumococcal meningitis (NB: though Pneumococcal menigitis is more known to cuase hearing loss: this is a separate issue, though).

c] When used, DXM should be given immediately before or at the time antibiotics are started. Once ABx have been begun, DXM is unlikely to improve the outcome for patients with BM.

That is why you might have seen the practice of giving IV dexamethasone 20 min before starting IV Antibiotics.

2. Non-Lactose Fermenters: Remember the mnemonic " SPACE"

Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter.

3. Advise to a mother for her newborn:

a] Start breast-feeding at one breast and change to another after 10-15 min of feeding. When you start breast feeding next time, start from another breast.

b] Exclusive breast-fed babies require multi-vitamin supplements.

c] Exclusively breast-fed babies should be started on Vitamin D 400 Units per day within 2 months of birth.

d] Pattern of supplemental foods:

4- 6 Months:

Is the time to initiate supplemental foods. Start single grain infant cereal with a spoon (2- 3 x/day)

6-9 Months:

Milk: 3- 4 feeds/day (24- 32 Oz /day)

Continue infant cereal (rice, oatmeal, barley; no wheat until 9 Month of age). Also give strained or mashed vegetable or fruits (It is generally advised that weaning should be started with cereals, and then vegetables and then fruit. Because fruit acceptability is good, thus if you start fruit firts, infant will be reluctant to take other stuff).

Tell mom to give fruit juice only when the baby is able to take in a sippy cup (4- 6 Oz max/day).

NB: Each new food be tried alone for 3- 5 days before introducing another new food.

9- 11 Mo:

Milk: 3- 4 feeds per day (16- 32 oz). Also, at 11 -12 months, introduce whole milk in a cup.

If mom wants to give egg to the baby: use egg yolk first, then introduce whole egg (yolk is less allergic).

This is also the age to try strained meats,yogurt, cheese, tofu, Finger foods

12 Mo:Whole milk in a cup

All finger foods are okay, except foods with the potential of choking hazards (whole grape, nuts, popcorn).

To quantify, milk intake for various age:

0-2 Mo: 16- 32 Oz

2- 4 Mo: 20-3 6Oz

4- 6 Mo: 24- 40 Oz

6- 9 Mo: 24- 32 Oz

9- 11 Mo: 16- 32 Oz

12 Mo: 16- 20 Oz

Hygiene practices in the newbron : Instruct the mom while she is taking care of a newly discharged neonate:

a] Use only lukeworm water on your baby's face. A mild soap such as Dove unscented, Neutrogena, Basis or Leve 2000 may be used on the rest of the body.Do not use ivory soap. Sponge bathe until the umbilical cord comes off.

b] Care of umb cord: clean the umb cord at every diaper change with alcohol pads/swabs/ or soaked with a q-tip. Make sure to get down to the base of the cord. The cord usually falls off in 10-21 days.

When the cord drops off, the baby may begin to take the tub baths.

c] Lotions are unnecessary if you are using a moisturized soap as previously mentioned. It may be used if the skin is excessively dry.

4. Isolation precautions:

a] Parvo virus: Fifth disease: When rash appears, patient is no longer contagious.

NB: In sicklers infected with Parvo virus: Longer isolation (droplet precaution) is needed ,because patient sheds virus for longer time.

b] Infectious mononucleosis:

No isolation required. But physical rest is imposed to avoid risk of splenic rupture. The exact guidelines are:

Restriction in physical activity is needed for 4 weeks whether spleen is palpable or not. After 4 weeks, the Pediatrician examines the patient again, if spleen is still palpable: more physical rest is imposed.

5. Risk of infection following a deer tick bite of developing Lyme disaease: 2- 4 % in Long Island,NY. It is 95 % in shelter island.

6. Two ways to diagnose Lyme disease:

a] ELISA test: 10 % false positives

b] Western blot: confirmatory

7. Ch. Lyme disease does not need antibiotic treatment.

8. Deer tick: is the vector for Lyme disease

All ticks have 8 legs, so do spiders. Thus if a mom brings a bug to the ER or your office, that does not have 8 legs, it is not a tick.

Deer Tick has a SCUTUM (dark colored head like). Thus if you see a scutum, it is deer tick.

Some types of ticks:

Deer tick: Ixodes sp

Dog tick: Dermacenter sp

Lone star tick

9. A mom calls your office or ER and she is concerned about a tick-bite and hence Lyme disease, ask her to bring the tick if possible): At your office or ER you figure out that it is a deer tick. Thus treatment of the patient is based upon:

## If tick was attached for >72 hrs (index of engorgement): Give once single dose of doxycycline prophylaxis.

10. Post -Bone Marrow transplant:

The main concerns are:

0- 1 Month after the BM transpalnt: : Neutropenia,line infections, nosocomial infection, resp infection are the main concerns.

1- 6 Mo: CMV, EBV, PCP

> 6 Mo: Fungal, CMV

In transpalnt patients:

a] Always try to identify the infections in recepient (i.e,patient: which you will of course as described above), but also in donors (like, whether donor was + for CMV or not!)

b] Always place PPD before transplant.

11. Ranitidine can cause neutropenia.

12. Proning in patients of ARDS:

In PICU, you see that patients of ARDS are made to lie down in prone position (from usual supine). This helps re-distribut the debris of lungs, and helps improve V/Q mismatch.

13. Landau- Kleffner syndrome (LKS) and KLS (Kleine Levin Syndrome).

14. Dysautonomia is a disorder of peripheral nervous system. There are 2 classes: familial dysautonomia (Riley day syndrome) or a non-familial dysautomomia.

15. Cocaine: As we know it is a substance known for its abuse potential.

Whereas, Cockayne Syndrome: AR, DNA repair defect

Edward Alfred Cockayne (1880–1956), after whom this disease is named, was a London physician who concentrated particularly on hereditary diseases of children.

Cockayne syndrome is a rare inherited disorder in which people are sensitive to sunlight, have short stature, and have the appearance of premature aging. In the classical form of Cockayne syndrome (Type I), the symptoms are progressive and typically become apparent after the age of 1 year. An early onset or congenital form of Cockayne syndrome (Type II) is apparent at birth.

NB: Interestingly, unlike other DNA repair diseases, Cockayne syndrome is not linked to cancer.

16. Do you know that melatonin has a role to play in sleep! I know an infant who slept very less when he was about 6 months old. After a lot of frustation and non-intervention recommended by his peditrician, parents insisted for Melatonin levels measurement. They were found to be low, the patient was started on sublingual mealtonin supplement as BID doses and he showed inmprovement.

17. Amantadine: for influ A; Oseltamivir: for flu B

Note: amantadine not effective for flu B.

18. Tick-borne diseases in USA:

The ticks that transmit these diseases belong to the family Ixodidae, also known as hard ticks.

Remember 3 types of above ticks: 1.Blacklegged tick/ Ixodes scapularis 2. Dog tick/ Dermacenter variabilis 3. Lone star tick/ Amblyomma americanum


20. Hurler Syndrome:

a] is type I MPS. AR
b] X ray findings: Oar-shaped ribs: narrow at the origin, become wider as they go towards insertion. 'Beaking' of vertebrae. Narrowing of lower ileal segment.

c] Urine screening reveals metachromasia because of excretion of Glycosaminoglycans. Dx is established by measuring activity of the lysosomal alpha-iduronidase in peripheral WBcs.

d] Rx: Children with severe form of MPS benefit from 'STEM cell Transplants'. This results in attenuation of neurological progression, improved mobility and quality of life, and longer lifespan. Children with attenuated form of the disease can now be trated with specific enzyme replacement therapy: Laronidase (brand name Aldurazyme) . It improves mobility, exercise tolerance, and cardiac function.
Theapies for other MPS are or soon will be available, including type 6 (Marateaux- Lamy disease: galsulfase, brand name Naglazyme), and type 2 (Hunter Syndrome: idursulfase, brand name Elaprase).