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Clinical Issues in Children: Diagnosis and Management

Explore approaches to diagnosis and treatment of common pediatric clinical issues including growth, development, anemia, abdominal pain, diarrhea, and infectious diseases. Learn about ethical considerations, differential diagnosis, and practical management strategies.

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Clinical Issues in Children: Diagnosis and Management

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  1. UF Service TripsCommon Clinical Issuesin Children Rob Lawrence, MD Pediatric Infectious Diseases

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

  3. 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.

  4. Growth, Development and Anemia • Growth: WHO Child Growth Standards Multicentre Growth Ref. Study (MGRS) Stunting, wasting, malnutrition • Development: Assessment Tools Observation • Anemia: Age, WHO standards Correlation with IQ, development and association with intestinal parasites • Breastfeeding: WHO Recommendations MGRS – standards, potential AHRQ report #153 -07-E007 www.ahrq.gov Breastfeeding: More than just good nutrition. Lawrence RM Peds in Rev 2011;32;267.

  5. Growth Stunting 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) • Height-for-age is less than -2 SD (below the mean) • Chronic undernutrition - retards linear growth

  6. Growth Wasting 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* • 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* Black RE et al. Lancet 2008, 371:243-60. Maternal and Child Undernutrition Study Group:

  7. Kwashiorkor • Growth Failure • Wasting – muscles • Edema – abdomen, scrotum, feet • Hair changes • Mental changes / activity • Dermatosis • Appetite diminished • Anemia • Fatty lliver

  8. Principles of Treatment forSevere Malnutrition Ashworth A et al. Child Health Dialogue Issue 3 + 4, 1996 10 Steps – Guidelines for treatment of Severely Malnourished Children

  9. Malnutrition • Calories • Protein • Micronutrients Vitamin A Iron Iodine Zinc Disease Control Priorities in Developing Countries Stunting, Wasting and Micronutrient Deficiency Disorders Caulfield LE, Richard SA et al. Chapter 28

  10. Micronutrient Deficiency

  11. Development

  12. Anemia Screening: all children 1-6 years old, girls / women >12 years old Treatment: 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)

  13. Abdominal Pain DiarrheaIntestinal 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

  14. 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

  15. 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: labsonly for chronic diarrhea, or persistent bloody d. • Therapy: avoid antibiotics unless febrile, anti-diarrheal meds are ineffective / not advised in children, ORT, nutrition, education Keusch GT et al. Diarrh. Diseases. C 19 Dis Control Priorities in Dev Countries

  16. Parasites

  17. Important Arthropod-borne Illness Malaria - 2009 Dengue - 2010 WHO Reports

  18. Comparison Dengue 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 • 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

  19. Antimalarial Drugs

  20. 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 - deltoid Protection – meningitis, miliary TB Effect on TST – cutoffs, < 5yrs, >15 mm • Multi-drug Resistant TB = MDR-TB Poor-compliance, mutations Co-infection with HIV + TB Inadequate infrastructure / Public Health / DOT

  21. Tuberculosis • Dx: clinical, CXR, smears, AFB, uncommonly culture, DNA • Rx: Isoniazid Rifampin (rifamycins) Pyazinamide Ethambutol 2o line agents Directly Observed Therapy (DOT) Public Health

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

  23. BCG Scars

  24. TST Reactions

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