NICE indications for CT scan following traumatic head injury in children

NICE has proposed indications for CT scan following traumatic head injury in children in 2014. The indications are given below:

Any of:
• Suspicion of non-accidental injury
• Post-traumatic seizure
• Glasgow Coma Score (GCS) <14 on arrival at emergency department (<15 for <1 year of age)
• GCS <15 two hours after injury
• Suspected open or depressed skull fracture
• Evidence of basal skull fracture
• Focal neurological deficit
• Presence of bruise or swelling >5 cm in
diameter in children aged <1 year

More than one of:

The Common Cold In Pediatric Practice

The common cold is a viral infection with prominent symptoms of rhinorrhea and nasal obstruction, absent or mild fever and lacking systemic manifestations.

Etiology
The viruses primarily involved with colds are rhinoviruses and less commonly coronaviruses. Other viruses that cause common cold symptoms as part of broader clinical syndromes include respiratory syncytial virus and less commonly influenza viruses, parainfluenza viruses and adenoviruses.

Pathophysiology
Viral infection of the nasal epithelium causes an acute inflammatory response with mucosal infiltration by inflammatory cells and release of inflammatory cytokines. The inflammatory response is partly responsible for many of the symptoms.

Clinical FeaturesCommon cold symptoms typically develop 1 to 3 days after viral infection and include nasal obstruction, rhinorrhea, sore or scratchy throat and occasional non productive cough. Colds usually persist about 1 week although 10% lasts 2 weeks. there is often a change in color or consistency of nasal secretions, which is not indicative of sinusitis or bacterial superinfection.

Examination of the nasal mucosa may reveal swollen, erythematous nasal turbinates.

Management Of Status Epilepticus In Children

Definition Of Status Epilepticus
Status Epilepticus is defined as ongoing seizure activity for greater than 20 minutes or repetitive seizures without return of consciousness for greater than30 minutes.

Any child presenting with status epilepticus is at a risk of irreversible brain injury and needs immediate management:

Initial Stabilization

1. The first priority of treatment is to ensure an adequate airway and to assess the cardiovascular status i.e look for ABC = airway, breathing and circulation.

2. Maintain an IV access.

3. Oxygen is administered and pulse oximetery observed.

4. ECG monitoring is done.

5. If violent muscle activity impairs ventilation, muscle paralysis and sedation should be instituted.

6. Immediate laboratory tests that need to be done include:

• Blood glucose
• Basic metabolic panel (sodium, calcium, magnesium)
• Antiepileptic drug levels
• Toxicology screening

Basic Laboratory Tests For Fever In Children

Fever is one of the most common presenting symptom in pediatric practice and has a number of different causes. Sometimes the concerned physician needs to do some basic laboratory workup apart from a detailed history and physical examination to reach the definitive diagnosis and determine the cause of fever.

Laboratory Workup

1. CBC with differential
Often over utilized in well appearing febrile children. High WBC is a risk factor for bacteremia in a highly febrile child. Low WBC count is not a reliable predictor of one specific disease as it may be seen in viral infections, overwhelming infections ( including meningitis) and in immune deficiency states.

The differential helps in identifying acute or chronic infections. In acute bacterial infections there is increased neutrophil count .

2. Lumbar PunctureAlthough not done in all children with fever it is a gold standard for diagnosis of meningitis and must be performed whenever history and physical examination are pointing towards the risk of having meningitis.

3. Blood Culture
It has a little value to assess for occult bacteremia (bacteremia unexpected on clinical grounds). Most of these episodes are benign and resolve without treatment. Children who develop serious deep infections often present for medical care before positive test for blood culture. Multiple (3 or 4) blood cultures are warranted when certain diseases e.g osteomyelitis, endocarditis are suspected, to increase their yield. Blood cultures should be obtained through central lines if present.

4. Urinalysis
It is a useful test in female children without other evidence of infectious foci; it has significantly lesser yield in male children but should be considered in uncircumcised boys during infancy if fever is not self limited. Urine nitrities, leukocyte esterase , Gram stains and direct cell visualization add to the immediate diagnostic value of urinalysis.

Understanding Some Common Symptoms Seen In Infants

Some of the common symptoms seen in infants ( young children upto one year of age) are summarized as below:

1. Crying
Parents commonly report problems about a crying baby, in the first 3 months of life. In most of the cases no cause is found. Crying peaks at 6–8 weeks old (~3h/day, worse in the evenings) and subsides by 4 months. Cries of hunger and thirst are indistinguishable.
Sometimes a crying baby makes a disturbed parent angry and if mother has been suffering from postpartum depression it can worsen it. Sometimes it is OK to leave a baby crying if it is in the
child’s best interests. A baby who is abused due to excessive crying would rather have been left alone.
The following measures can be done for a crying baby:
• Don’t make parents feel inadequate; Explain them the normal crying and sleeping pattern of babies appropriate for the age. Parents can take turn in looking after the baby.
• Help parents recognize when their baby is tired and hungry and to apply a consistent approach to care.
• Vocal (singing), vestibular (rocking, going for a drive) or tactile stimulation (hugs) may help. Encourage help from friends/family. Simplify daily living.
• If not coping, admit to a parenting center or hospital.

Management Of Diabetic Ketoacidosis

Therapy for patients with diabetic ketoacidosis DKA involves careful replacement of fluid deficits, correction of acidosis and hyperglycemia via insulin administration, correction of electrolyte imbalances and monitoring for complications of treatment.

1. Dehydration
A patient with severe DKA is assumed to be approximately 10% dehydrated. An initial IV fluid bolus of a glucose-free isotonic solution ( normal saline, lactated Ringer’s solution) at 10-20 ml/kg should be given to restore intravascular volume and renal perfusion. The remaining fluid deficit after the initial bolus should be added to maintenance fluid requirements, and the total should be replaced slowly over 36 to 48 hrs. To avoid rapid shifts in serum osmolality, 0.9% sodium chloride can be used as the replacement fluid for the initial 4 to 6 hrs followed by 0.45% sodium chloride.

2. Hyperglycemia
Fast-acting soluble insulin should be administered as a continuous IV infusion (0.1U/kg/hr). Serum glucose concentration should decrease at a rate no faster than 100 mg/dl/hr. When serum glucose concentration decreases to less than 250-300 mg/dl, glucose should be added to IV fluids.

3. Acidosis
Insulin therapy lowers glucagon and diminishes its activity on liver, decreases the production of free fatty acids and protein catabolism, and enhances glucose usage in target tissues. theses processes correct acidosis. Bicarbonate therapy should be avoided unless there is severe acidosis ( pH < 7.0).

4. Electrolyte ImbalancesRegardless of the serum potassium concentration at presentation, total body potassium depletion is likely. When adequate urin output is shown potassium should be added to the IV fluids. Potassium replacement should be given as 50% KCl and 50% KPO4 at a concentration of 20-40 mEq/L.

5. Monitoring
A flow sheet should be used to record and monitor fluid balance and laboratory measurements. Serum glucose measurements should be repeated every hour during therapy and electrolyte concentrations should be repeated every 2 to 3 hours. Calcium, phosphate and magnesium concentrations should be measured initially and then every 4 to 6 hours during therapy.

Physiology Of Hemoglobin

Hemoglobin is a iron containing protein in the red blood cells that carries oxygen in the blood from the lungs to the rest of the body tissues. A normal hemoglobin level is necessary for the normal function of the body. If there is decreased or abnormal hemoglobin synthesis it results in number of different diseases.

Here we will discuss the brief physiology of hemoglobin in the human body which helps in understanding the diseases related to abnormal hemoglobin.

Hemoglobin Synthesis

• Erythropoietic activity is regulated by erythropoietin.
• The mitochondria of the developing erythroblast are the main sites for the sythesis of haem.
• The globin protein part is synthesized in the ribosomes .
• There are number of complex series of steps for the synthesis of hemoglobin.
• The Vitamin B6 acts as a cofactor in the process of synthesis.
• The Fe is supplied by the circulating transferrin.
• A tetramer of four globin chains, each with its own haem group attached, is formed to make a molecule of hemoglobin.

Structure and Different Types of hemoglobin
Hemoglobin has a quaternary structure characteristic of many multi-subunit globular proteins. This structure comes from its four subunits arranged roughly in a tetrahedral pattern.

HbA: In adult humans, the most common hemoglobin type is a tetramer (which contains 4 subunit proteins) called hemoglobin A, consisting of two alpha and beta subunits non-covalently bound, each made of 141 and 146 amino acid residues, respectively. This is denoted as alpha2beta2. The subunits are structurally similar and about the same size. Hemoglobin A is the most intensively studied of the hemoglobin molecules.

Managing A Child With Raised Intracranial Pressure

Raised intracranial pressure may occur in a number of different medical or surgical conditions but whenever present rapid intervention is important to reduce the morbidity and mortality associated with it. Therapies differ some what based on etiology, although some generalization do apply. Therapy should be started as soon as raised ICP is suspected. Care should be coordinated with a pediatric neurosurgeon.

1. Immediate Actions
Immediate actions should always include proper evaluation and management of patient’s airway, breathing and circulation. Cerebral perfusion pressure should be adequate to provide blood flow to the brain.

2. Position Of The Patient
Simple first maneuvers should include having child lay supine, with head of bed elevated to 30 degrees and child’s head in a midline position. Use care when positioning the head of a trauma patient with potential cervical spine injury.

3. Ventilation
Maintaining adequate oxygenation and ventilation is of primary importance.Because CO2 is a cerebral vasodilator , maintaining normal PaCO2(40mmHg) helps decrease ICP by decreasing cerebral blood volume. Hyperventilation is indicated only in the setting of impending herniation.

4. Osmotic Therapy
Osmotic therapy consists of either mannitol (0.5-1 g/kg) or 3% saline (3-5 ml/kg). Both agents helps in reducing ICP.

5. Sedation and Seizure Control
Adequate sedation and keeping patient calm helps to reduce ICP and brain injury by reducing oxygen demand of the brain cells. In a similar fashion, control of seizure activity is beneficial both in reducing ICP and in reducing brain’s oxygen requirements. Barbiturates are often used to produce sedation, coma and seizure control.

Neonatal Galactorrhea - Milk production in Newborns (Witch's Milk)

Neonatal galactorrhea occurs in up to 6% of term newborns and is usually secondary to transplacental transfer of maternal estrogen. These hormonal effects (maternal estrogens and endogenous prolactin) lead to palpable breast buds in approximately one-third of all term newborns. Males and females are equally affected. In most cases, the breast enlargement and galactorrhea begin to subside after the second week of life in males and 2 to 6 months in females.

                                       Milky fluid draining from the nipple in a newborn

Infants with neonatal breast hypertrophy may be predisposed to infections (mastitis or abscess) possibly incited by repetitive manipulation of the enlarged breast bud by a caregiver.

The differential diagnosis includes early mastitis with purulent nipple discharge.

Management:
Treatment is not necessary unless infection is suspected. Parents can be reassured that this is a normal finding, and followup to resolution should occur at routine well child care visits.

Introduction To Malaria

Malaria is a disease caused by a Plasmodium parasite that is transmitted through the bite of female Anopheles mosquitoes. A patient with a fever for more than 48 hours in the endemic area should always be suspected for malaria.

Plasmodium Species
Plasmodium is an obligate intracellular protozoa and there are four species that includes:

1. Plasmodium Falciparum: causing the most serious infection with complications.
2. Plasmodium Vivax: have hepatic stages and may cause relapses of infection
3. Plasmodium Ovale: may cause a relapse similar to vivax
4. Plasmodium malariae

Life Cycle of the Parasite
Plasmodium exists in a variety of forms and has a complex life cycle that enables survival in different cellular environments in the human host and the mosquito vector. There are two major phases in the life cycle:

1. Asexual Phase(Schizogony): it occurs in the humans. The Erythrocytic phase of plasmodium asexual development begins when the merozites released from exoerythrocytic schizonts in the liver penetrate erythrocytes. When inside the erythrocyte , the parasite transforms into the ring form, which enlarges to become a trophozite.

2. Sexual Phase(sporogony): it occurs in the mosquito when the mosquito bites an infected human and gets the trophozoites which then complete the sexual cycle and becomes the sporozoite that travels to the salivary glands and can be then transmitted to another human by the mosquito bite.

Mode of transmission
The parasites usually are transmitted to humans by female Anopheles mosquitoes. Malaria can also be transmitted through blood transfusion, via contaminated needles, and transplacentally to a fetus.

Different Causes Of Altered Mental Status In Children

Coma may be caused by a number of different causes and the etiologies may be divided into structural or medical causes.

Structural Causes
Tend to result in asymmetric or focal neurologic findings, particularly affecting pupillary response, extraocular movements and motor response to pain.

1. Trauma: Typically involves a shearing mechanism (diffuse axonal injury) from rapid deceleration. This shearing forces can rupture blood vessels and result in subdural, epidural or intraparenchymal hemorrhage. When suspected mechanism of injury does not fit extent of patient’s injuries, always consider inflicted trauma or child abuse.

2. Tumor: If a child has a brain tumor symptoms such as headache,vomiting or focal neurologic deficits are typically present for weeks to months. Coma or altered mental status can result from seizures, intracranial hypertension or cerebral edema.

3. Cerebrovascular Event: Hemorrhagic and ischemic strokes occur with the same frequency in children. A ruptured arteriovenous malformation is the most common cause of hemorrhagic stroke in children. Ischemic and thrombotic strokes occur most commonly in children with sickle cell disease and congenital heart defects; less commonly in children with hypercoagulable states, metabolic disorders, vasculitis and other vascular abnormalities. Patients with hemorrhagic stroke tends to present with coma or altered mental status and those with ischemic stroke present with focal neurological deficits.

4. Hydrocephalus: Infants with this condition have an increased head circumference and it is due to increase in the CSF that may be due to a blockage in CSF flow or increased production. Patients may present with coma, altered mental status or irritability and poor feeding.

5. Infection: CNS infection from any source is a cause for confusion, coma or altered mental status.

Approach To A Child With Dysuria

A child may present with difficult or painful urination and it is important to ask a few questions that will help to reach an appropriate diagnosis.

Immediate Questions

1. When did the painful urination begin?
Trauma to the urinary tract must be ruled out if pain develops after an injury. Bicycle and straddle injuries commonly cause damage to the kidneys or urethra, leading to hematuria or dysuria or both. Consider behavioral problems , including attention seeking , if symptoms occur only at a particular time of day (e.g during school)

2. Where is the pain located?
An older child can locate the pain in the urethra, in the pelvis or in the abdomen. some children alos complain of a back pain. Pain originating from other organ system may be referred to the urethra. an intra abdominal abscess or a low lying inflamed appendix may produce complaints of dysuria. Dysuria associated with back pain is a common presentation of pyelonephritis. Renal stones in the pelvis, calyx, or ureter can cause abdominal or flank pain with radiation into the scrotum or vulva. Stones in the urethra or distal ureter Stones in the bladder are not associated with pain.

Dehydration And Fluid Management In Children

Introduction
Total body fluid is higher in children than adults. At birth, the body is made up of 80% water. By adulthood it is only 55–60%. Water is distributed two thirds in the intracellular space and one third in the extracellular space (divided 75% interstitial and 25% intravascular). The distribution of water between these compartments depends on the pressure and osmotic gradients between them.

Dehydration
Dehydration is loss of water and electrolytes.

Causes Of Dehydration in Children: Children may become dehydrated from:
• Reduced oral fluid intake: reduced appetite due to illness, vomiting, sore throat
• Additional fluid losses: fever, diarrhea
• Increased insensible losses: increased sweating, tachypnoea
• Loss of the normal fluid-retaining mechanisms: capillary leak, burns, the permeable skin of premature infants, increased urinary losses secondary to renal disease.

Infants and young children are more prone to dehydration than older children and adults because:
• Their body is made up of more water
• They have a high surface area in relation to their height or weight (high surface area : volume
ratio)
• They have relatively high evaporative water losses
• They have a higher metabolic rate and so higher turnover of water and electrolytes
• They rely on others to give them fluids.

Long Term Asthma Management

Children with asthma need a stepwise approach to classify the disease severity and guide treatment appropriately. The number and frequency of medications increase (stepup) as the need for asthma therapy increases and decrease (step down) when asthma is under control.

Persistent asthma is more effectively controlled by long term treatment to suppress and reverse the inflammation than by only treating acute broncoconstriction and related symptoms.

Treatment is reviewed every 3 to 6 months once asthma is under control.

Classification Of Asthma Severity

1. Severe Persistent AsthmaPatients have continuous symptoms with limited physical activity and have frequent night time symptoms. PEF is 60% of predicted with variability more than 30%. Long term preventive treatment include high doses of inhaled corticosteroids 800- 2000 mcg along with anti leukotrines. Also add long acting bronchodilator either inhaled or oral form. Give long term corticosteroid tablets on lowest possible dose on alternate days.

Child’s Developmental Milestones- Gross Motor

Developmental and behavioral problems are very commonly seen in pediatric practice.

Child development refers to how a child becomes able to do more complex things as they get older. Development is different than growth. Growth only refers to the child getting bigger in size.

Gross motor development refers to how a child begin to use large groups of muscles to sit, stand, walk, run, etc., keeping balance, and changing positions.

The First Month

• During the first month of life most of a baby’s behavior is reflexive, meaning that his/her reactions are automatic.
• Moves head side to side.
• When held upright, holds head erect and steady.

1 to 3 Months

• Lifts shoulder while prone.
• Supports upper body with arms when lying on stomach
• Stretches legs out and kicks when lying on stomach or back
• Opens and shuts hands

4th Month

• Lifts up on hands.
• Rolls front to back.
• If pulled to sit from supine , no head lag.

6th Month

• Pulls self up to sit and sits erect with supports.
• Sits alone.
• Rolls over prone to supine.

Management Of Cystic Fibrosis

Cystic fibrosis is an inherited disorder that causes thick, sticky mucus to build up in the lungs, digestive tract, and other areas of the body. It is one of the most common chronic lung diseases in children and young adults. It is one of the life-threatening disorder.

As cystic fibrosis leads to complex and multisystemic involvement patients need care by specialists, treatment and follow-up care at specialty centers with multidisciplinary care teams.

Although there is no cure for cystic fibrosis there are several treatment methods available to control the symptoms and to prevent complications.

The primary goals of CF treatment include the following:

• Maintaining lung function as near to normal as possible by controlling respiratory infection and clearing airways of mucus.
• Administering nutritional therapy (ie, enzyme supplements, multivitamin and mineral supplements) to maintain adequate growth.
• Managing complications.

Pharmacological treatment

• Antibiotics: to treat and prevent lung infections
• Mucus-thinning drugs: to help you cough up the mucus, which improves lung function
• Bronchodilators: to help keep your airways open by relaxing the muscles around bronchial tubes
• Oral pancreatic enzymes: to help digestive tract absorb nutrients.

Introduction to Attention Deficit Hyperactivity Disorder

Definition
Attention deficit hyperactivity disorder (ADHD) is a disorder that appears in early childhood and is characterized by a child’s behavior that consists of difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity).

Causes:
Still the exact cause of ADHD is not known but it is suggested that the genes, environmental factors and nutrition all play some role. Also studies have shown that this disorder can run in families and is also linked to smoking and alcohol during pregnancy.

Clinical Features:
The most obvious sign of ADD/ADHD is hyperactivity. While many children are naturally quite active, kids with hyperactive symptoms of attention deficit disorder are always moving.

Major symptoms of inattention include:

• Difficulty focusing on one thing.
• Easily distracted.
• Trouble completing homework assignments.
• Disorganized work habits.
• Getting bored with a task after a few minutes.
• Not seem to listen when spoken to.

Vitiligo In Children

Definition of Vitiligo:
It is a type of skin disorder in which there is a loss of skin pigment or color which leads to white patches all over the body.

Causes:
The exact reason what causes vitiligo to develop is still unknown but research shows that certain factors like autoimmune disorder, stressful event, harm to skin due to sunburn or cut, exposure to certain chemicals or a viral cause may be involved.

Pathophysiology:
Melanocytes are the cells located deep within the epidermis and are responsible for producing melanin which gives gives skin its color and helps protect it from the sun. Vitiligo develops when these skin cells suddenly stop producing melanin. Initially the effected skin gets lighter in color but eventually it spreads to cover a much larger area producing depigmented spots. It can effect any part of the body.

It is impossible to predict how much of the skin can be affected. In the majority of cases, the affected areas remain affected for the rest of the person’s life.

Clinical Examination In Pediatric Population - A Brief Summary.

A single routine usually does not work for all children. If the child is very ill, examination is limited. Also, points in the examination assume varying importance depending on age (for neonates,it may be different). But it is helpful to have some sort of standard:

Here we Take an example of a a boy of 3 years who is being seen because of vomiting.
Not everything mentioned in this summarized article will need to be done. The more experienced you are, the better you will be able to judge when and how to take short cuts. Don’t mistake taking short cuts for being lazy. Use the time saved to be available to answer questions, and to address the fears and hopes of the parents and child.

Important to Note: there is no correct order: be opportunistic, e.g with younger children on a lap listen to heart when there are gaps in crying.

1 Wash and warm your hands. Encourage both parents to be present.

2 Regard the child (e.g while feeding).

• Is he ill or well?
• Restless, still, or playing?
• If crying, is it high pitched or normal? 
• Is he behaving normally? 
• Any jaundice, cyanosis, rashes, anaemia, or dehydration?
• Is he moving normally? 
• Does anything hurt, e.g neck, abdomen, limbs?

3 Talk to the child. Explain what you are doing. This helps you both relax, and enjoy the occasion (not a trivial point: a happy doctor is an engaged doctor; an engaged doctor is more open to subtle signs). If he seems anxious, examine his teddy in a playful way, to allow him to build up trust. Asking
about pets or siblings often helps.

Approach To A Child With Recurrent Fever

Fever is one of the most common medical signs and is defined as a condition in which the body temperature elevates above the normal range of 36.5–37.5 °C (97.7–99.5 °F).

Recurrent fever: Recurrent fevers are defined as three or more febrile episodes in a six-month period, occurring at least seven days apart, with no causative medical illness. These episodes can occur at regular or irregular intervals.

Causes: Although the exact data is unknown the most common diagnosis associated with this fever pattern is PFAPA syndrome (i.e., periodic fever, aphthous ulcers, pharyngitis, and adenopathy).

PFAPA syndrome typically causes fevers every 4 weeks lasting 5 days. Parents will often be able to predict within several days the onset of the next fever attack.The syndrome usually occurs in children younger than five years who present with regular fevers and cervical adenopathy. Aphthous ulcers, which are usually small and relatively painless, are the symptom most likely to be missed. Children with PFAPA syndrome are well between episodes and relatively well even during episodes.

The other common cause of recurrent fever in children is cyclic neutropenia (CN).

Patients with cyclic neutropenia (CN) suffer from fevers lasting 4-5 days every 2-3 weeks, slightly more frequently than PFAPA patients. Interestingly, symptoms of PFAPA and CN are very similar including oral aphthae, cervical adenopathy, and pharyngitis.

Introduction To Neonatal Jaundice

Neonatal jaundice is the yellowing of the skin, sclerae, and/or mucous membranes caused by bilirubin deposition.

It occurs when total serum bilirubin is in excess of 5 mg/dL and progresses in a head-to-toe fashion as levels increase. Most cases of physiologic (<12 mg/dL) jaundice are self-limited without sequelae, and appear on the second or third day of life peaking between the third and fifth day. Preterm infants may peak later.

Pathophysiology: The increased bilirubin production in newborns is a result of turnover of fetal red blood cells, a temporary decrease in conjugation and clearance by the immature newborn liver, and increased enterohepatic circulation.

Risk factors for indirect hyperbilirubinemia include

• maternal diabetes,
• prematurity, 
• drugs, 
• polycythemia, 
• traumatic delivery with cutaneous bruising or hematoma, 
• breastfeeding, and 
• ABO (O mother and A/B infant) or Rh(D) incompatibility (Rh(D) negative mother and Rh(D) positive infant). 

Immediate Care Of Newborn Baby

Introduction: The birth of a newborn is a great moment and amazing physical changes occur soon after birth. The newborn is completely dependent on others for feeding, warmth, and comfort. 

Labor, birth and the immediate postnatal period are the most critical for newborn and maternal survival.

Physiologic Respiratory and Circulatory changes at Birth:
When the baby is delivered, the umbilical cord is cut and clamped near the navel. This ends the baby’s dependence on the placenta for oxygen and nutrition. As the baby takes its first breath, air moves into the lungs. Before birth, the lungs are not used to exchange oxygen and carbon dioxide, and need less blood supply. The fetal circulation sends most of the blood supply away from the lungs through special connections in the heart and the large blood vessels. When a baby begins to breathe air at birth, the change in pressure in the lungs helps close the fetal connections and redirect the blood flow. Now blood is pumped to the lungs to help with the exchange of oxygen and carbon dioxide. Some babies have excess amounts of fluid in their lungs. Stimulating the baby to cry by massage and stroking the skin can help bring the fluid up where it can be suctioned from the nose and mouth.

Newborns who do not start breathing on their own by one minute after birth should receive positive pressure ventilation with room air by a self-inflating bag and mask.

School Phobia In Kids

Introduction:
School phobia, School avoidance or School refusal are the terms used to describe a condition in which a child refuses to go to school on a regular basis and has an irrational persistent fear of going to school. These children want to stay in close contact with their parents or a care giver and often feel insecure, sensitive and have difficulty to cope with their emotions.

Symptoms:
A child having school phobia usually complains of physical symptoms just before the time for school and these may include headache, stomachache, nausea, diarrhea etc. If the child is allowed to stay home the symptoms disappear quickly, just to return the next day again before going to school. The child may even have nightmares and trouble going to sleep. He may have fear of dark or staying alone as well as too much separation anxiety when required to leave the parent or caregiver leading to clinginess, tantrums and panic.

Cause:
In order to find out the reason behind this fear and refusal for school it is important to consider issues at home as well as school. Some of the causes include:

• A child who has experienced a recent family change for example death, divorce, illness etc
• Recent move or financial problems at home
• Having been absent from school for long due to some illness
• A fear that something will happen to parent when he is at school
• A need to get parents attention when not at school.
• A fear of criticism or punishment by teacher at school
• Having some underlying undiagnosed learning difficulties.
• Being afraid of not getting the perfect test scores
• A victim of peer bullying at school
• Fear teasing due to appearance of clothes, height, weight etc
• Difficulty adjusting with a new school
• Difficulty adjusting with a new teacher at school
• Fear of using school restroom.

Introduction to Temper Tantrums

What is Temper Tantrum?A temper tantrum is a sudden unplanned display of anger, frustration or other emotion by a young child. It is just not an act to get attention. It usually last for 30 seconds to 2 minutes being more intense in the beginning. During a temper tantrum a child often cries, yells and swings his/her arms and legs.

Some Information About Temper Tantrums:Every new parent as well as teachers to young children should know about temper tantrums and what to expect and how to manage if a child has temper tantrums.

• Temper tantrum or ‘acting out’ behavior is normal part of growing up and natural during early childhood.
• It can be seen in children ages 1 to 4 years , usually beginning when a child is about 12-18 months old, get worse at age 2-3 years and then decrease by age 4 years.
• Temper tantrums are equally common in both boys and girls.
• There may be predictable situations that may trigger the tantrums like bedtime, suppertime, bath time etc.
• More than half of the young children will have one or more tantrums a week when they vent their frustration and protest their lack of control.

Characteristics of a Temper Tantrum:
During a temper tantrum a child may shout, whine, complain, resist, cling, throw stuff and defy the parents or the teacher. A temper tantrum is just a way to express the feelings for which a child cannot find words. Young children don’t have any evil plans to disturb their parents on purpose, it is simply a way they express their frustration. Although it is a normal behavior for age it becomes a problem when they occur with greater frequency, intensity and duration than is typical for the age of the child.

Eating Disorders In Children

Introduction:
Eating disorder may be defined as an unhealthy approach to eating, weight and exercise. It is something more than just refusal to eat. When this problem occurs in children or teens it leads to serious changes in eating habits that may sometimes even be life threatening.

Incidence: Eating disorders usually appear in adolescence or early adult hood but it may be seen in children also. Females are much more vulnerable. Unfortunately in recent years children diagnosed with a case of eating disorder is increasing. A child as young as 7 years can even be diagnosed with an eating disorder. According to a survey done in year 2002 it shows that 28% of girls in grade 9 were engaged in some kind of eating disorder in order to loose weight.

Symptoms to Look For In Children With Eating Disorder: In young children and adolescents it is difficult to identify a eating disorder since children differ in their weight and nourishment naturally according to their growth spurt. If a child is not eating good enough during the growing stage the height may be compromised. Also it is difficult to distinguish between an eating disorder and common food behaviors in young children like picky eating and fussiness. Here are a few symptoms that should be noticed in order to identify a child having some kind of eating disorder.

• Refusal to eat
• Body image concerns
• Social withdrawal
• Fine hair growing on the body
• Weight loss or failure to gain weight
• Lack of growth
• Thinning hair on head
• Refusing to sit still
• Abnormal activities like excessive moving of legs, running around and standing and refusal to sit
• Hiding food
• Personality changes like depression or anxiety
• Menstrual abnormalities in young girls.
• Throwing up just after eating.

Hunter Syndrome - A Rare Genetic Disorder

Introduction:
Hunter syndrome is a rare genetic disorder that occurs due to a deficiency of an enzyme. It is a Lysosomal storage disease and the deficient enzyme is iduronate-2-sulfatase. As a result the long chain of sugar molecules ( mucopolysaccarides) are not broken down by the body and start to accumulate. The accumulated substrates are heparan sulphate and dermatan sulphate. This syndrome has X linked inheritance and so the boys are mostly affected. It is also known as Mucopolysaccharidosis II.

Clinical Features:
The symptoms of Hunter syndrome are usually not apparent at birth. The signs and symptoms usually start to appear around the age of 18 months. The condition varies from patient to patient with some having only minor problems while others showing very sever problems. The signs and symptoms include:

• Growth delay resulting in a short stature
• Delayed development with late walking.
• Change in facial features like thickening of the lips, tongue and nostrils.
• Aggressive behavior.
• Mental function getting worse over time with intellectual disability.
• Claw like hands
• Abnormal bone size and skeletal irregularities.
• Enlarged internal organs like liver and spleen leading to a distended abdomen
• Abdominal hernias.
• Recurrent ear infections, runny nose and cold.
• Deafness getting worse over time.
• Joint stiffness.
• Cardiovascular disorders like progressive thickening of heart valves leading to impaired heart function, high blood pressure and obstruction of blood vessels.
• Respiratory difficulties.
• Carpal tunnel syndrome.

Clinical Features Of Acute Leukemia In Children

Acute Lymphoblastic Leukemia is the most common childhood Leukemia. 

The Clinical Features are briefly summarized here:

1. Patients usually present with signs of bone marrow failure with anemia, Thrombocytopenia and Neutropenia.

2. Fever is also one of the most common presenting symptom in acute Leukemia.

3. Some patients complain of bone pains, arthritis and limping which is most common with B-precursor acute lymphoblastic leukemia.

4. In patients with mature B-ALL there may be signs of CNS involvement like headache, vomiting, lethargy, nuchal rigidity etc.

5. Patients with a T cell lineage ALL there may be symptoms of respiratory distress due to a mediastinal mass.

6. Easy bruising or bleeding with petechiae due to decreased platelet counts.

7. Pallor, Lethargy and tiredness due to anemia.

8. Repeated infections along with fever because of low white cell count.

Clinical Signs And Symptoms Of Thalassemia Major

Thalassemia major is a type of hemolytic anemia that is cause by a mutation in the Beta chain of hemoglobin that causes lysis of the red blood cells , decreased hemoglobin and resulting in anemia. This is a genetic condition that is passed from parents to children.

Pathophysiology: Normal adult hemoglobin has two beta chains and two alpha chains. In patients with Thalassemia major there is no normal gene for beta chain synthesis and thus there is no normal production of hemoglobin A. This leads to a significant anemia and illness.

Clinical Signs And Symptoms:

1. At birth a baby with thalassemia major seems to be completely normal, healthy and active, It is because at birth the predominant hemoglobin is the fetal hemoglobin that does not need the synthesis of beta chain.

2. Later on within the first few months after birth when the body starts to replace fetal hemoglobin with adult hemoglobin symptoms begin to appear gradually. Anemia begins to get progressively more and more severe.

3. The child fails to grow normally and shows signs of severe fatigue and lethargy. The child may have difficulties with feeding due to easy fatigue because of lack of oxygen and underlying severe anemia.

4. The child may look pale and may have repeated attacks of fever and diarrhea.

5. Liver and spleen are enlarged leading to a distended abdomen.