Pediatrics- Ward Notes (Part IV)

Here are some notes from around the wards during my rotation in pediatrics. Enjoy:


Common causes of Hematuria:
Acute glomerulonephritis, IgA nephropathy, Stones, Urinary tract infection, Clotting disorders, Trauma, Drugs, PSGN

Severe complications of Acute GlomeruloNephritis:
Acute renal failure (anuria), Hypertensive encephalopathy, Left ventricular failure

During the 1st year of life, UTI is more common in males with an M to F ratio of 4:1.
Pyelonephritis characteristically presents with- Fever, Chills, Costovertebral tenderness

Strong indicators of UTI in a Urine D/R: (Multiple organisms usually indicate contamination)
Abnormal color or clarity, > 100,000 of the same organism/ ml, Nitrites +ve, Leukocyte esterase +ve
Damaged RBC casts in urine indicate Glomerular origin.
Creatinine is preferred over BUN because BUN is easily altered by dehydration and starvation while Creatinine is kidney function specific.

-Remember to ask about the number of stools/day because constipation is a risk factor for UTI. Examine the spinal cord.
-When did the child last urinate? If more than 6 hours, then suspect Acute Renal Failure.

Causes of Recurrent UTI:
Hypospadias, Meatal stenosis, Urethral/Ureteric stricture, Renal agenesis, Polycystic kidney disease, Horse-Shoe kidney, Obstruction at the PelvicUreteral Junction, Posterior Urethral Valve

When counseling for urine collection, ask mother if her child informs her when he wants to micturate.

Suprapubic Puncture: Procedure
Bladder should be full (>2 hours since last micturition). Palpate pubic symphysis and then puncture 2-3 cm above in the midline (avascular linea alba). The 10 gauge needle should be perpendicular. Next, aspirate urine out and then seal it. Remember, this is a blind procedure.
Complications- Infection, Trauma, Perforation

Posterior Urethral Valve:
Obstruction at the bladder neck because of posterior mucosal membranes. May present at any age despite being congenital.
Male child, Early presentation, Failure to grow, Oligohydramnios, Anemia, Acidosis, Increase in BP, Big bladder, Palpable kidneys

Investigations- CBC, Urine D/R, UCE, U/S KUB (echogenicity, corticomedullary differentiation, size, diameter, VUR), MCUG, DMSA scan (assess renal function)

Immediate treatment includes bladder decompression via catheterization. Surgical ablation via transurethral approach.

MCUG-
Investigation used for VesicoUreteral Reflux. One should look at the level of dilation of the ureter and the amount of dilation in the calyx and renal pelvis. Normally, contrast should not reflux into the ureters. Posterior urethral valves present as a black band (does not take up dye), between the bladder and urethra.
Urination begins in utero at the 12th week of gestation. Oligohydramnios may result in severe pulmonary hypoplasia. Therefore, a vesicoamniotic shunt should be created.

Ultrasound Kidney:
Echogenicity is compared to the echogenicity of the liver and spleen. The kidneys are normally less.
A dilated pelvis may indicate pelvoureteric stenosis.

DMSA Scan- Used to assess kidney function. A dye is taken up by the renal cortex.
DTPA- glomeruli
MAC 3- Tubules

Causes for Unilateral Kidney damage- Stones, Aberrant vasculature, Ureterocoele, abnormality of the PUJ (can be bilateral)

Grade I or II Hydronephrosis can be treated medically. The patient is advised to 'double micturate'.
Grade IV or V Hydronephrosis is treated surgically. Procedures include reimplantation of the ureters and Deflux surgery.

Management of VUR depends on the degree of damage. The bladder or urethra may need to be completely replaced.


Cesarean section and bottle fed babies are more prone to develop asthma when they grow up.
There is a high association between bronchiolitis and asthma.
A silent chest is a very severe condition.

Chest X-Ray in Asthma patients show streaky hilar shadows, hyperinflation, tubular heart
When Peak Expiratory Flow Rate is graphed, X-axis shows the value while the Height is plotted on the Y-axis.
Honey water or yakhni soup (Pakistani origin) can be given to clear secretions in mild asthma.
Asthma is diagnosed after the 3rd attack.
Status asthmaticus is diagnosed if the 3rd dose of short acting Beta agonists (bronchodilators) does not provide relief. Aminophyllin and steroids should be started.

Eosiniophilia in kids may be seen in:
Asthma, Ascaris infection, Loffler's syndrome, Hay fever, Hookworm infection

Differential Diagnosis for recurrent chest infections:
Cerebral palsy, GERD, Diaphragmatic hernia, DiGeorge’s syndrome, Fungal infection, Heart abnormalities, Pneumonia, Congenital bronchiectasis, Cystic fibrosis, Kartagener’s syndrome

Chest Physiotherapy- Since children under the age of 2 are unable to expectorate, physiotherapy is done to help remove secretions. Lay the child in the lateral tredelenburg position and percuss from below upwards on the chest. This is indicated in Bronchiectasis.

Neonatal Meningitis- E. coli, Group B streptococci, Klebsiella
Infantile Meningitis- H. influenza type B, S. pneumoniae, N. meningitidis
Tubercular Meningitis- glucose levels are low. Choroid Tubercles may be seen in the fundus of the eye
Viral- glucose levels are normal
Herpes- blood may be seen in the CSF
CSF- If there is an increase in lymphocytes, then the origin may be Tubercular, Viral, or partially treated bacterial. Glucose values are the last to change.

A single dose of antibiotics can render a Lumbar Puncture sterile. In such cases, Latex Particle AGglutination should be carried out.
Gram staining, and Herpes PCR can also be performed with CSF along with culture and sensitivity.

Band cells- Are immature neutrophils which signify overwhelming acute bacterial infection. Their nuclear material is arranged in a band within the cell.

Lymphocytic leukocytosis is seen in- Leukemia and Whooping cough

Chloride sweat test (uses pilocarpine) in a suspected Cystic Fibrosis case will be >80 mg/dL.

Barium meals show: Diaphragmatic hernia, Sliding hernia, Achalasia, Esophageal Stenosis/Atresia

Mumps- Advise not to eat sour foods. Complications include meningitis, otitis media, orchitis (males)

Flag sign- Seen in Kwashiorkor. Area of hyperpigmentation alongside an area of depigmentation

Cerebral Palsy- Non-progressive, permanent disorder of posture and movement that is usually a developmental problem. Mental retardation may be associated. Requires multi disciplinary management.

Ampicillin and Gentamycin are given prophylactically to cover gram +ve and gram -ve bacteria.

Dengue antibodies are seen 5 days after the fever begins.

Specific Typhoid investigations- Typhi dot and Bone marrow culture
Cross reactivity amongst Typhoid and Malaria is possible. Previous IgG typhoid is possible with vaccination.
Carriers for typhoid are identified as having three +ve consecutive stool cultures.

Causes of Pancytopenia:
Sepsis, HIV, Megaloblastic anemia, TB, Hypersplenism, Aplastic anemia

Thrombocytosis may be seen in Iron deficiency anemia and Kawasaki's disease.

Causes for Thrombocytopenia:
ITP, Sepsis, Malaria, Hemolytic ureamic syndrome, Hypersplenism, Dengue, TORCH infections, Iatrogenic, DIC, CLD, Hemangioma


Pakistan Statistics-
6 children are born every minute in Pakistan.

Neonatal Mortality rate is 40/1,000 live births, 20 of which are due to birth asphyxia.
Under 5 Mortality rate is 56/1,000 live births.
Perinatal Mortality rate (28 weeks gestation till 7 days after birth) is 60/1,000 live births.
Infant Mortality rate is 91/1,000 live births.
Maternal Mortality Ratio is 276/10,000.


Resuscitation Trolly:
Ambu bag (30-40 mm Hg pressure in infant type), Heater, ET tube (2.5 - 7.0), Laryngoscope, Mouthpiece, Epinephrine, Vitamin K, I/V chamber.

Incubators are used to regulate ventilation and temperature at 37 C degrees.
Blue light is usually used for phototherapy but cyanosis may not be seen. Hence, a yellow light may be used.

Babies at risk for Hypoglycemia- Birth asphyxia, Prematurity, Infants of Diabetic Mothers

If a neonate is limp, apply a painful stimuli. Start CPR when HR <>

Indomethacin is given for a duration of 3 days only after platelet and creatinine levels are termed normal.
Survanta- 4 mL/kG via endotracheal tube.

APGAR score of >7 is considered good.



As this is a series, there will be more to come soon!