Pediatric Annotations # 4

1. DDH:
i] Developmental dysplasia of hips is no longer called Congenital Displocation of Hip (CDH) because it has been seen that dislocation of hips can occur after birth also (in infancy).

ii] Click Versus clunk: Click is what you feel, while clunk is one that we hear also. These are not exact definitions as there is no common agreement on these two terms.

iii] Provocative testing includes the Barlow and Ortolani maneuvers, which involve adduction of the flexed hip with gentle posterior force, and abduction of the flexed hip with gentle anterior force, respectively. The Barlow test attempts to identify a dislocatable hip, while the Ortolani exam attempts to relocate a dislocated hip. Due to variations in technique, the Barlow and Ortolani tests have been shown to have a high degree of operator dependence.

iv) Incidence less in cultures (example, India) where there is a practice of mothers carrying the baby on their sides.

2. Note that under 18 years of age, all vaccines are gievn as 0.5 ml with these exceptions:
*Flu shot: under 36 months: 0.25 mL, after 36 to 59 months: 0.5 ml
*Rotateq: 2 mL

3. P/F ratio:
PaO2/ Fio2. Normal >200; In ARDS it is <200.

4. Definition of ARDS:

i] Acute onset or following a catastrophic event
ii] Diffuse B/L disease on CXR
iii] P/F ratio of <200
iv] Non-cardiac origin of pulmonary disease

5. Pathology of ARDS:
a] Increased permeability of alveolar-capillary memebrane: This leads to decreased compliance, decreased FRC, and increased dead space
b] Pulmonary HTN
c] Pulmonary shunting

6. Treatment of ARDS:

a] Vent strategy:
* High PEEP/MAP * Prone position
* iNO (because Pulm HTN occurs in ARDS and hence iNO will help)
* And of course ECMO
NB: In ARDS, another vent strategy is to employ Inverse ratio ventilation. This means: breath starts before expiratory flow from prior breath reaches baseline --> Auto-PEEP with recruitment of alveoli. The Cx of this strategy: #Increased MAP results in decreased cardiac output; # pneumothorax, # Co2 retention. b] Steroids

7. West Nile Fever: culex mosquito spreads it.

8. CPAP Vs BiPAP (Bilevel positive Airways Pressure).

In BiPAP, we set two different pressures for inspiration and expiration.

9. ADHD:

a] While asthma affects 8 % of pediatric population, ADHD has a prevalence of 3- 8 %. Thus ADHD is also a fairly common disease.

b] The meds (stimulants) help 2 components: Inattention and hyperactivity. Over last many years, pharmaco-therapy has gained a wider beneficial acceptance.

c] Questionnaires for testing for ADHD:

1. Connors Scale: cumbersome

2. ADHD Rating Scale (De Paul): easier and popular (our B & D Clinic uses it all the time)

3. Vanderbilt scale also good.

d] ADHD can be diagnosed not generally before 3 years of age. If a for eg a 2 yrs kid hyperactive, and you feel that she/he fits in the mould of ADHD, still you are not going to treat this kid by medication anyway as the dx is generally not made in kids less than 3 years of age.

10. Tests for assessing Development:

A] Based upon information from parents:

1. PEDS ( Parents' Evaluation of Developmental Status)

2. Ages and Stages Questionnaire 3. Infant Development Inventory

B] Based upon eliciting skills from children:

1. DDST II: Denver

2. CAT/ CLAMS Development Assessment: infact our B&D likes it extensively. 0-36 months

3. BINS (Bayley Infant Neurodevelopmental Screen) 3- 24 Mo

4. BDIST ( Battelle Developmental Inventory Screening Test) 12- 96 Mo