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Paediatrics


DISEASES


Is It Asthma?


Consider asthma if any of the following signs or symptoms are present:
 Frequent episodes of wheezing- more than once a month
 Activity induced cough or wheeze.

Cough particularly at night during periods without viral infections.
 Absence of seasonal variation in wheeze
 Symptoms that persist after age -3
 Symptoms occur or worsen in the presence of:
    1. Aeroallergens (house dust mites, companion animals, cockroach, fungi)
2. Exercise
3. Pollen
4. Respiratory (viral) infections
5. Strong emotional expression
6. Tobacco smoke
 The child colds repeatedly "go to the chest” or take more than 10 days to clear up.
 Symptoms improve when asthma medication (short acting bronchodilator or inhaled corticosteroid) is given.

Differential Diagnosis of Asthma in children 5 years and younger
Infections:-
 Recurrent respiratory tract infections
 Chronic rhino-sinusitis
 Tuberculosis
Congenital Problems:-
 Tracheomalacia
 Cystic Fibrosis
 Bronchopulmonary dysplasia
 Congenital malformation causing narrowing of the intrathoracic airways
 Primary ciliary dyskinesia syndrome
 Immune deficiency
 Congenital heart disease
Mechanical Problems:-
 Foreign Body Aspiration
 Gastroesophageal Reflux

Levels of asthma control in children 5 years and younger

Characteristic
Controlled
(All of the following)
Partly controlled
(Any measure present in any week)
Uncontrolled
(Three or more of features of partly controlled asthma in any week)
Daytime symptoms: wheezing cough, difficult breathing
None
(Less than twice / week typically for short periods of on the order of minutes and rapidly relieved by the use of a rapid-acting bronchodilator)
More than Twice / week
(typically for short periods on the order of minutes and rapidly relieved by the use of a rapid-acting bronchodilator)
More than Twice / week

(typically last minutes or hours or recur, but partially or fully relieved with rapid-acting bronchodilators)

Limitation of activities
None
child is fully active, plays and runs without limitation or symptoms)
Any
(May cough, wheeze, or have difficulty breathing during exercise, vigorous play or laughing)
Any
(may cough, wheeze, or have difficulty breathing during exercise, vigorous play or laughing)
Nocturnal Symptoms / awakening
None
(including no nocturnal coughing during sleep)
Any
(typically coughs during sleep or wakes with cough, wheezing and/or difficult breathing)
Any
(typically coughs during sleep or wakes with cough, wheezing and/or difficult breathing)
Need for reliever / rescue treatment
<= 2 days / week
> 2 days / week
> 2 days / week

Asthma Management Approach Based on control for children 5 years and younger
Asthma Education
Environment Control
As need rapid-acting beta2 agonist

Controlled on as needed
rapid-acting beta2 agonists
Partly controlled on as needed rapid-acting beta2 agonists
Uncontrolled or only partly controlled on low-dose ICS*
Continue as needed rapid-acting beta2 agonists
Low dose ICS
Leukotriene modifier
double low dose ICS
Low dose ICS plus leukotriene modifier

  *Oral glucocorticosteriods should be used only for treatment of acute severe exacerbations of asthma.
Shaded boxes in this table represent the preferred treatment options:

Low daily doses* of inhaled glucocorticosteriods for children 5 years and Younger
Drug
Low Daily Dose(µg)
Beclomethasone Dipropionate
100
Budesonide MDI † spacer
200
Budesonide Nebulized
500
† Ciclesonide
NS
Fluticasone Propionate
100
† Mometasone Furoate
NS
† Triamcinolone Acetonide
NS

*A low daily dose is defined as the dose which has not been associated with clinically adverse effects in trails including measures of safety. This is not a table of clinical equivalence.

† NS means Not Studied in this age group

Choosing an inhaler device for children with asthma
Age Group
Preferred Device
Alternative Device
Younger than 4 years
Pressurized metered dose inhaler plus dedicated spacer with face mask
Nebulizer with face mask
4-5 years
Pressurized metered dose inhaler plus dedicated spacer with mouthpiece
Pressurized metered dose inhaler plus dedicated spacer with face mask
or
Nebulizer with mouthpiece or face mask


Initial management of acute severe asthma in children 5 years and younger
Therapy
Dose and Administration
Supplemental Oxygen
Deliver by 24% face mask (flow set to manufacturer instructions, usually 4L/min)
Maintain oxygen saturation above 94%
Short acting beta2 agonists
2 puffs salbutamol by spacer
or
2.5 mg salbutamol by nebulizer
Every 20 minutes for first hours
Ipratropium
2 puffs every 20 minutes for first hour only




When to call the doctor?

 Repeated vomiting, especially if it upsets the child.
 Frequent loose or abnormal motions.
 Persistent crying, indicating pain somewhere.
 Sudden shrieks of pain, even if not repeated in a short while.
 Difficulty with breathing.
 Any abnormal discharge, especially from the ears.
 Any sudden change in the child’s appearance making him look ill.

Safety Tips
 Keep all medicines out of your child’s reach in a closed compound.
 Check all electrical wires to see that they are not frayed or damaged.
 Fit safety socket covers on all electrical points.
 Lock away all pins needles scissors, matches, lighters, knives or other sharp object.
 Never leave your child unattended in a high place, kitchen or bathroom.
 Keep aerosol cans, sprays, toilet cleaners etc. out of your baby’s reach.
 Don’t leave plastics bags lying around. Once over a child’s head, they could cause suffocation.
Breast Feeding is the best feeding. It should be started as soon as possible after Delivery. Colostrums  (Breast milk for first 2 Days) is very important for the child’s health. Exclusive Breast feeding is recommended for the first 4-5 months. Feed in a position with the baby’s head held higher. Burp the baby  after every feed. No additional water or supplements are required for the first 4-5 month.
 Bottle feeding is dangerous for the child in many ways. Use cup and a spoon instead.
 Keep the body (especially the newborn) warm.
 Avoid, oil/buds instillation in nose/ ears & kajal application to eyes.
Weaning ( addition of semisolid feeds) is recommended from the 5th month onwards. Soft rice, kanji, thin       dal, mashed boiled potatoes, soft mashed banana etc., are recommended weaning feeds. Vomiting may occur in the initial stages till the child gets used to the feed. Hence introduce only one feed at a time.
 Gradually add semisolid and solid feeds, including green leafy vegetables.
 Generally cereals, pulses, green leafy vegetables, eggs, fish, jiggery & groundnuts are required for a          balanced diet.
 Keep medicines , kerosene and other poisonous product away from the reach of children ( especially            toddlers)
 Follow up the growth pattern of your child regularly.



Table1 : Blood Pressure levels for the 90th and 95th Percentiles of blood pressure for boys aged 1 to 17 years by percentiles of height


Table2 : Blood Pressure levels for the 90th and 95th Percentiles of blood pressure for girls aged 1 to 17 years by percentiles of height



Table3 : Centile table for girls



Table4 : Centile table for boys



Table5 : Surface Area nomogram