Download Clinical presentation:

Project Title
Paediatric
A research presented by
Student name:
Student No:
Dalia kamal
9760111
Project supervisor: Dr. RAFEEQ ABU SHAABAN
Second semester .2001
Ajman University for Sciences and Technology
Abu Dhabi Branch
UAE
Research for this project was carried out by me during the period of
Hospital Pharmacy Training-2 no.700315(academic year 2000-2001)
Signed
2001
Date June 18
ACKNOWLEDGMENTS
Sincere gratitude
pharmaceutical
were
extended
department, to
to Dr. Rafeeq Abu Shaaban from
the
support, encouragement and
the
fruitful
accompaniment through out the training and presentation of this project.
Special project
supervisor Dr RAFFEQ , for
the
continuous
follow
up ,
constructive criticism , and valuable comments. The author is indebted to
The author wishes to express special gratitude and thanks to those contributing
in this revolutionary, distinctive and advanced Hospital Pharmacy training 2;
namely Dr.Danna Sallam and the staff of the New Medical Center Hospital .
2
INDEX
Description
Section l
Page no
Introduction
4
1.0 Drug disposition
4
1.1 Drug therapy in children
6
1.2 Monitoring parameter
9
1.3 Adverse drug events
10
1.4 Counseling and compliance
11
1.5 Medicine in school
1.6 Communication with paediatric patient
1.7 Vaccine and vaccination for paediatric
11
13
14
1.8 pharmacoeconomics
16
1.9 cost of different drugs used for paediatrics
17
Section 11
clinical cases for paediatric
18
2.0 A child with fever (1)
18
2.1 A child with pneumonia and heart failure (2)
22
2.2 A child with vomiting (3)
28
2.3 Cranky child (4)
31
2.4 A child with anaphylactic shock (5)
34
2.5 Twins with abdominal infection (6)
35
2.6 A child with asthma (7)
36
2.7 A child with acute hematogenous osteomyelitis (8) 38
2.8 A child with pneumonia (9)
40
2.9 A child with sore throat (10)
42
Section III conclusion
45
3
Paediatrics
Introduction
Pediatrics is the branch of medicine dealing with development, diseases and disorders
of children. For many purposes it has been common to subdivide childhood into the
following periods:
* Neonate: the first 30 days of life.
* Infant: from 1 month to 1 year.
* Child; from 1 tear to 12 years.
For the purpose of drug dosing, children over 12 years of age are classified as adults
.the (BPA) have suggested that childhood is divided into the following age ranges:
- Neonate: birth to 1 month (subsection: infants under 37 weeks gestation)
- Infant: from 1 month to 2 years.
- Child: from 2 to 12 (subsection: children under 6 years old need appropriate
formulations)
- Adolescent: from 12 to 18 years.
These age ranges are intended to reflect biological changes. The newborn (birth to 1
month) covers the climacteric changes after birth, 1 month to 2 years the early growth
spurt, 2 to 12 years the gradual growth spurt and 12 to 18 years the adolescent growth
spurt to final adult high. It is hoped that these age ranges will be used as the standard
reference range in future.
Infancy and childhood is a period of rapid growth and development. The various
organs, body systems and enzymes that handle drugs develop are different rates and
present a challenges to those who specialize in pediatrics, since drug and adverse
reactions vary throughout childhood. Compared with adult medicine, drug used in
pediatrics is not extensively researched and the range of linced drugs in appropriate
dosage forms is limited.
DRUG DISPOSION
Pharmacokinetic factors
An understanding of the variability in drug disposition is essential if children are to
reactive an appropriate drug therapy. For convenience the factors that affect drug
disposition will be deal with separately. however when treating a patient all the
factors have dynamic relation ship and none should be considered in isolation.
Absorption
Oral absorption. The absorption process of oral preparation may be influenced by
factors such as gastric and intestinal transient time, gastric and intestinal PH and
gastrointestinal contents. Posture, Disease State and therapeutic intervention such as
nasogastric aspiration or drug therapy can also affect the absorption process.
Few studies have reported on absorption in older infants or children. The
bioavalibility of sulphonamide, digoxin and phenobarbitone has been studied in
infants and children of wide age distribution. Despite the different phisicochemical
proporties of the drugs , a similar bioavalibilty pattern was observed in each case. The
4
rate of absorption was correlated with age, being much slower in neonates than in
older infants and children. These data suggest that in older infant and children orally
administered drugs will be absorbed at a rate and extent similar to those in healthy
adults. Changes in the absorption rate would appear to be minor important when
compared to the related differences of drug distribution and excretion.
Intramuscular absorption. Absorption in infant and children after IM injection is
noticeably faster than in the neonatal period, since muscle blood flow is increased. on
a practical note, IM administration is very painful .
Intraosseous absorption. It is useful in whom IV access can’t be obtained and used
in cardiorespiratoy arrest where rapid access is required .in children less than 5 years
of age the bone marrow of the long bones is predominantly vascular red marrow, but
in older age groups this is gradually replaced with less vascular yellow marrow .
Topical absorption. Patch formulations of hyoscine hydrobromide have been found
to be very useful to dry up secretions in children with excess drooling. Percutaneous
absorption, which is inversely related to the to thickness of stratum corneum and
directly related to skin hydration, is generally much greater in the newborn and young
infant than in adult. This can lead to adverse reaction. For example the topical
application of a preparation containing prilocaine and lignocaine is not recommended
for use in children under 1 year of age. This because of its absorption and can lead to
methamaglobinaemia.
Rectal absorption. The rectal rout is less favorite. It is used in-patient who are
vomiting, or in infant and children unable to take oral medicine.
Distribution
A number of factors that determine drug distribution within the body are subjected to
change with age. These include vascular perfusion, body composition, and tissue –
binding characteristics and the extent of plasma protein binding. As a percentage of
total body weight the total body water and extracellular fluid volume decrease with an
age. Thus for water soluble drugs larger doses on a million gram per kilogram of body
weight basis are required in the neonate than in the older child to achieve similar
plasma concentration.
Protein binding despite normal blood PH , free fatty acid and bilurubin levels in
infants , binding to plasma proteins is reduced as result of low concentration of both
globulin and albumin. It has been suggested that binding values comparable with
those seen in adults are reached within the third year of life for acidic drugs, where for
basic not reached. The clinical reduction in infants is minimal. The influence of
disease states, such as renal impairment.
Extracellular fluid volume and total body water as a percentage of body weight.
age
Preterm neonate
Term neonate
3 month
1 year
adult
Total body weight%
85
75
75
60
60
5
Extracellular fluid%
50
45
30
25
20
Drug metabolism
At the majority of the enzyme systems responsible for drug metabolism are either
absent or present in reduced amount compared with adult values, and evidence
indicates that the various systems don’t mature at the same time. This reduced
capacity for metabolic degradation at birth is followed by a dramatic increase in
metabolic rate in the older infant and young child. In 1 to 9 age in particular,
metabolic clearance of drug is shown to be greater than in adults.
Renal excretion
The anatomical and functional immaturity of the kidneys at birth limit ranal excretory
capacity. Below 3 to 6 months of age the glomular filtration rate is lower than that of
adults, but may be partially compensated by greater reduction in glomular function.
Other factors
In addition to age – related changes in drug disposition, nutritional status and disease
status can influence drug handling. High plasma clearance of antibiotics has been
demonstrated in children with cystic fibrosis; increased elimination of frusemide has
been reported in children with the nephrotic syndrome whilst prolonged elimination
of frusemide has been reported in infants with congestive heart failure. Altered
protein binding has been demonstrated in hepatic disease, the nephrotic syndrome ,
malnutrition and cardiac failure.
Drug therapy in children
Dosage
Children should not be treated as mini- adults, yet pediatric dosages are often
extrapolated from the usual adult dose. Rather than calculate the proportion of the
adult dose it is preferable to consult a textbook or vade mecum in which pediatric
doses confirmed by clinical experience. Much different formula based on age and
weight has been developed for estimating a child dose from adult value. Whilst age,
weight, and height are the easiest parameters to measure, the changing required for
drug dosage during childhood correspond most closely with changes in body surface
area. (BSA) nomogram which allow the surface area to be easily available. The
surface area can also be calculated by the following formula:
BSA= height (cm) * weight (kg)
3600
Children less than 1 year of age have a proportionally larger surface area than other
age groups. Therefore in oncology, where surface area are routinely used, dosages
based on weight rather than surface area are often specified to prevent overestimation
of dose in this age group.
There are practical problems in using the surface area method for prescribing;
accurate height and weight may be difficult to obtain in a sick child , and
manufactures rarely provide dosage information on a surface area basis . the surface
area formula for children has been used to produce the percentage method , giving the
percentage of adult dose required at various age and weight .
6
In selection a method of dosage calculation the therapeutic index of drug should be
considered. For agents with narrow therapeutic index where recommendation are
quoted per square meter, dosing must be based on calculating surface area. However
for drugs with height therapeutic index, single dose may be quoted in milligram per
kg and this is the most widely used in calculation. The resulting dose for each method
is modified according to response and adverse effect.
It is important to note that none of the available methods of dosages calculation
account for the change in dosage interval which should may be required because of
age – related changes in drug clearance. Where possible. The use of therapeutic drug
monitoring to confirm the appropriateness of a dose is recommended.
Choice of preparation
The choice of preparation and its formulation will be affected by the intend rout of
administration, the age of the child, availability of preparation, other concomitant and,
possibly, underlying disease state.
Oral route
It is usually the most convenient, but in an uncooperative child it can be the least
reliable. Safe and effective drug therapy requires accurate administration, yet the 5-ml
spoon is a difficult means of administering liquid medicine. Use of the oral syringe
can overcome some problems and avoid the need for dilution of preparation with
syrup.
In general, liquid preparations are most suitable for children of less than 5 years of
age, although many quit young children can cope with solid dose formulation. Some
commercially available products contain excipients such as alcohol, propylene glycol
and dyes that may cause adverse effect for use in children with particular disease
states. The osmolality and tonicity of preparations may be important; narcotizing
entrocolitis has been associated with high – osmolality preparation infant feeding
formula and pharmaceutical preparation. Sugar- free preparation may be necessary in
diabetic child or be desirable in other children for the prevention of dental caries. It is
important to be aware of the potential problem associated with substitutes for sucrose.
The artificial sweating agent aspartame, used in some preparation, should be used
with caution in children with phenylketonuria because of it’s phenylalanine content.
Other carbohydrate such as sorbitol and glycrol may not contribute to dental caries
but produce diarrhea if large dose is given. In these instances a specially formulated
preparation may be preferable.
Injection solution can sometimes be administered orally although their concentration
and PH must be considered together with the presence of unsuitable excipients.
Powders may be prepared and used as alternative. However, lactose is a common
diluent in powders, and caution must be exercised in children. With lactose
intolerance as result of an inborn error of metabolism, or temporarily following
gastrointestinal disease or gut surgery.
Parents must be discouraged from adding the dose of medicine to infant feeds. Quit
apart from potential interactions which may rise with milk feed, if the entire feed is
not taken a proportion of the dose will be lost. It is important to advise parent when it
is not appropriate to crush solid dosage forms, e.g. sustained release preparation.
7
Rectal route
Although the rectal rout can be useful, it is limited by the range of products available
and the dosage inflexibility associated with rectal preparation.
When oral and rectal are inappropriate the parental route may be necessary.
Parenteral route
As previously stated, the intramuscular route of administration should be avoided in
children. However, intravenous administration is not without its preparation. In infant
and children the direct administration of intravenous fluid from the main infusion
container is associated with the risk of inadvertent fluid overload. A paediatric
administration set, incorporating a graduated volumetric chamber with a maximum
capacity of 150 ml should always be used. Although primarily a safety device, the
volume within the burette can be readily adjusted allowing its use for intermittent
drug administration and avoiding the need for ‘piggy back system’. Use of volumetric
infusion device to control the flow rate is also strongly recommended .
Parenteral products are associated with particular problems in paediatric therapy. The
concentration of many proprietary products makes measurement of the small dose
required very difficult and cal lead to inaccuracies. Reconsistution of powder
injections in accordance with manufactures’ direction usually makes no allowance for
the displacement volume of the powder itself. Under dosing may occur as a result,
since the final volume will be greater than expected and the concentration less than
expected.
Dilution of parenteral preparations for infusion often presents problems in paediatrics.
In fluid- restricted or very young infants, the volume of diluted drug can exceed the
daily fluid requirement. Often stability data on concentrated solutions are lacking, and
in this situation it may be necessary to manipulate other therapy to accommodate the
treatment or even consider alternative treatment options.
The slow infusion rates often necessary in paediatrics may influence drug therapy.
The greater the distance between the administration port and the distal end of the
delivery system, and the slower the floe rate, the longer the time require for drug
delivered to patient. In very young infants and children it may take several hours for
the drug to reach the paint. This is an important consideration if dosage adjustments
are being made in response to serum level monitoring. Bolus injection should always
be given as close to the patient as possible.
The trapping of a drug solution at the injection ports creates further problems for drug
administration. When dose volume are small the trapped fluid may represent a
considerable proportion of intended dose. Ensuring that drugs are flushed into the
main infusion line after administration via an injection port can help to minimize the
problem. Flushing volumes can add a significant amount to the daily fluid intake, and
may be important to record the volume of flushing solutions used in patient
susceptible to fluid overload.
8
Analogous to oral preparations, excipients may be present in parenteral formulations
and associated with adverse effects. Benzyl alcohol, polysorbates and propylene
glycol are commonly used agent which may induce a range of adverse effects in
children including metabolic acidosis, altered serum osmolality , central nervous
system depression, respiratory depression, cardiac arrhythmia and seizures.
Knowledge of products that contain these ingredients may influence drug selection.
Many hospitals have established centralized intravenous additive (CIVAS) that
prepare single intravenous doses under sterile conditions, thus avoiding the need for
preparation at ward level. Such services have been not only significantly decreased
the risk associated with intravenous therapy, particularly in the paediatric population,
but can be also produce considerable cost saving.
Pulmonary route
The use of aerosol inhalers presents particular problems for children because of the
coordination required. The availability of breath- activated devices and spacer devices
has greatly improved the situation.
MONITORIG PARAMETERS
Those who practice in paediatrics should be aware that paediatric vital signs and
hematological and biochemical parameters change throughout childhood and differ
from those in adult. The figures presented are given as example and may vary from
hospital to hospital.
Assessment of renal function
Several formulae and nomograms, such as that of cockcroft and gault , are available
for calculating and estimating renal function in adult, bur these cant be extraploted to
the paediateric population. Use of the equation suggested provides a simple estimate
of creatinine clearance for those between the ages of 1 and 18 years.
Creatinine clearance = 42 * height (cm)
Serum creatinine (mmol/l)
Paediatric vital signs
Age/
Heart rate (beats/min)
Blood pressure (systolic)(mmHg)
Respiratory rate (breath/min)
<1 year 2-5years 5-12 years
120-140 100-120 80-100
70-90
80-90
90-110
90
80
80
9
Adverse drug events
There are a paucity of formal prospective and retrospective studies examining the
incidence and characteristic of adverse drug reaction in the paediatric age group. The
incidence of adverse drug reaction increases with age. However, this dose not applies
to the neonatal period, during which the incidence of adverse drug reaction is also
increased. Neonates are susceptible to the adverse drug reaction because of a number
of factors. For example, they are more susceptible to the respiratory depressant effects
of opiates through several mechanisms; the increase permeability of the blood- Brian
Barrier altered receptor sensitivity and reduced clearance, compared with older
children. Th incidence of adverse drug reaction in children outside the neonatal period
is less than other ages; however, the nature and severity of the adverse drug
experience may differ. Typically they occur at lower doses than in adults, and
symptoms may be atypical e.g. discoloration of the teeth with tetracycline, growth
suppression with long term corticosteroids in prepubertal children, and 25% of
children treated with phenobarbitone will manifest paradoxical hyperactivity. The
reason for this is unknown and doesn’t relate to altered pharmacokinetics.
Medication errors are common cause adverse drug reaction in paediatrics and should
always be considered as possible causative factor in any unexplained situation. The
incidence of medication errors and the risk of serious errors occurring in children are
mush greater than in adults, and they’re many reasons for this. These include
problems with dosage calculations, this lack of standard doses in children because of
changes in weight, age and drug handling and the lack of suitable preparations for the
use in children and the need to extemporaneously prepare products. The reporting and
prevention of medication errors in paediatric is an important aspect of the paediatric
pharmacist role.
Biochemical and hematology references ranges
neonates
child
adult
Albumin (g/l)
24-48
30-50
35-55
Biluribin (mmol/l)
<200
<15
<15
Calcium (mmol/l)
1.8-2.8
2.15-2.7
2.20-2.55
Chloride (mmol/l)
95-110
95-110
95-105
Creatinine (mmol/l)
28-60
30-80
50-120
Haemoglobine
18-19
11-14
13.5-18 male
(g/dl)
12-16 female
Magnesium
(mmol/l)
Phosphate(mmol/l)
Potassium(mmol/l)
Sodium(mmol/l)
Urea(mmol/l)
White cell count
0.6-1.0
0.6-1.0
0.7-1
1.3-3.0
4.0-7.0
130-145
1.0-5.0
6-15
1.0-1.8
3.5-5.5
132-145
2.5-6.5
5-14
0.85-1.4
3.5-5.0
135-145
3.0-6.5
3.5-11
10
COUNSELING AND COMPLAINCE
Many health professionals often counsel the parents only, rather than involving the
child in the counseling process. A number of studies have been shown that parents
consider the 8 to 10 year age group the most appropriate to start including the child in
the counseling process. Moreover, parents want this information provided both
verbally and written. Unfortunately, current patent information leaflets must reflect
the data sheet recommendation, as well as being written in a style that is inappropriate
for children read they may also include statements such as ‘not recommended for use
in children’ if the medicine is being used off label. Care needs to be taken, therefore,
to ensure that information provided, whether written or spoken, is appropriate not
only for the child.
Ensuring that children comply with taking medicines presents a serious of additional
problems. In most cases the patient will be responsible for giving the child medicine
and therefore compliance is dependent on the parents. It has been shown that the more
serious a parents perception of the child’s medicines. Factors such as the formulation,
taste, ease of administration and appearance can be all-important factors when trying
to ensure that parent complain with all their medicine. The time of administration of
medicine may also lead to difficulties. Medicines should be arranged around the
child’s waking day. Very young children tend to sleep a great deal and wake when
hungry, and it is not always possible to give the medicine as prescribed .older children
and adolescents may be responsible for their own medicines, and different factors
become important. Children may be unwilling to use their medication, e.g. inhalers,
because of peer pressure, and this needs to be considered.
Medicine in school
Children who are acutely ill will be treated with medicines at home or in hospital,
although during their recovery phase it may be possible to return to school. Children
with chronic illness such as asthma or epilepsy, may require medicines to be
administered whilst at school. In addition there are some medical emergencies
services. These emergencies include anaphylaxis, sever ashram attack and fits.
There is considerable controversy over the administration of medicine in school.
Policies and procedures are require ensuring that prescribed medicines are labeled,
stored, and administered safely, and that teachers and care assistants are adequately
trained and understand their responsibilities. The administration of adrenaline by
injection and rectal diazepam cause particular and understandable concern to some
teachers. The school should have a policy on the use by pupils of ‘over the counter’
remedies and on the possession of all medicine. The school authority and teachers
unions must make clear statements about liability should be allowed to administer
their own mediation. Asthmatics should carry their reliever inhaler (salbutamol), a
spare should be available in school, and easy access before during sports assured.
There should be no need to have ‘preventer’ inhalers at school since twice or three
times daily administered schedules are appropriate and can avoid school hours.
11
Pharmacist can assist by recommending mending medicines with a 2 to 3 times daily
administration schedule so that dosing during school hours is avoided. Sustained
release preparation or drugs with long half-life may be more expensive but avoid the
difficulties of administered at school. When administration at school is unavoidable
the pharmacist in a separator container can provide the school time doses.
**Factors to be considered when selecting a drug
regimen or route of administration for a pediatric
patient.
factors
1* Age/ weight/ surface area
2* Assess the appropriate dose
3* assess the most appropriate interval
4* assess the route of administration in the light of the
disease sate preparations and the formulations
available.
5*consider the expected responses and monitoring
parameters
6*interaction
7* Legal consideration, if drug licensed or not.
12
COMMUNICATION WITH PAEDIATRIC PATEINT
The parent must provide the history when a child is still an infant or a toddler. As the
child becomes older is able and willing to talk to the health professional, he becomes
a valued historian. Unfortunately; many health professional neglected to include
children the gathering of history data. For example, provider may pleasantly introduce
himself and great the child but ignore him during the interview speaking exclusively
to parent. The rational often given for this type of behavior is that children think more
diffusely than adults, questing do them will prolong an interview, making it
inefficient. However since health care is being provided to the child, it is not fair to
exclude him if he is capable of providing some assurance. A child who is ignored in
an interview may feel unimportant or unneeded and he may continue to feel and act
this way with health professional an adulthood. Many children can respond to simple
directive question without delaying interview.
Many older preschool and young school- age children are quite eager to present their
perspective on their health or illness and are often more insightful than we might
imagine. Allowing such a child to tell you about his illness or health may offer an
important perspective and give the child a sense of control.
If the youngster is a percentage or an adolescent, he should be encouraged to be the
principal historian. He may be initially shy or awkward in relating the history, and the
parent might be interrupt to clarify. The younger should be given every opportunity to
present his story in his own way. This may necessitate having the parent leave the
room, which has potential of alienating the parent unless it is managed with
discretion. A simple comment such as” to help me provide better care, I’d like to talk
to you both together, and then with each of you alone” not only gives the parent the
rational for your speaking to the adolescent alone but also informs the parent leave the
room should not be forced to be interviewed alone. If parent objects to her child’s
being interviewed in her absences, it is necessary to find out what her concerns are
and to address them openly. This conversation may have to occur with the parent
alone.
It is quite common for pediatric health professional to talk to infants and toddlers in
affected tones of voice. However, when the child is older, it is advisable to be as
natural as possible. it is usually to unwise to speak to the child in the vernacular of the
street because it may be offensive. You may be the youngster’s ally, but you are not
this buddy. Many older children and adolescents is “son” “sweetie”. Find out what
they like to be called and respect their preference.
When asking about hobbies and interests, be polite and try to personalize unless the
patient asks for your level of interest. Some adolescents are skillful in diverting the
conversion away from them, particular if they are uncomfortable in discussing
themselves or a certain topic. The interviewer should attempt to keep things on track
without seeming to be offensive.
The history rendered by an adolescent is confidential, and should be discussed with
the parent or others without the knowledge and permission of the teenager. The same
confidentiality is due to the parents. This structure must be under stood by all of those
involved before the interview begins.
13
Vaccines and Vaccination for paediatrics
Definition of vaccines:
They are foreign proteins obtained from microorganisms and when injected into a
human system will start or initiate an immune response. Thus, the body will easily
deal with any future exposure.
Types of Immunity
* Natural
When a person gets a disease, the body will deal with it as antigens and hence
antibodies are formed as a response.
* Acquired
Active immunization:
This means the administration of antigens to the large to induce formation of
antibodies and cell-mediated immunity.
Passive Immunization:
This means the transfer of immunity to a host using performed immunologic effects.
MAJOR CLASSIFICATION
Local compulsory vaccines
Tuberculosis
Source: BCG vaccine (bacilli Calmat Guanine)
Type: Live attenuated mycobacterium Bo is
Route of administration: Subcutaneous, (I.D)
Given: First day of birth or maximum 1 week after birth.
Dose: 0.1ml
Hepatitis
Source: Hepatitis B virus and surface antigen
Type: Inactivated virus coat protein
Route of administration I.M
Given in the first day after birth and another dose after one month and the third dose
at the eight month.
14
Poliomyelitis
Source: poliovirus
Type: Attenuated.
Route of administration: orally
Given: 2 months after birth second dose in the eighteenth month.
Dose: 0.5ml or 2 drops.
DPT
Source: Diphtheria titans peruse
Type: Toxic
Route of administration: IM
Given from the second, forth, sixth and eighteenth month.
Dose: 0.5ml
MMR
Source: Measles virus, mumps virus, and rubella virus
Type: live viruses.
Route of administration: S.C
Given: at the fifteenth month
Dose 0.5ml
Homophiles Influenza infection
Source: p [polysaccharide protein
Type: polysaccharide protein (split virus)
Route of administration: I.M
Given In the second month followed by eighteenth month dose.
Dose 0.5ml
Meningococcal meningitis
Source is a polysaccharide given as S.C, Rifampcin antibiotic is given as a
prophylaxis.
Rabies :
A killed virus given as I.M and is the only vaccine given after the exposure to the
virus.
Major classification
1) Live but attenuated
2) Killed virus or bacteria
* Toxoid : toxins of bacteria
* Splito vaccine: part of the vaccine is given. Splito vaccine is preferred because
killed or attenuated vaccines maybe strong enough to cause side effects. On the other
hand using part of the vaccine or bacteria is enough for recognition without causing
any side effects.
* Booster: is the injection given and greatly elevates the immune response.
15
Route of administration
S.C, I.M, Oral, I.D, Rectal
Other none- compulsory vaccines
* Vaccine for influenza virus given I.M per year.
* Chicken pox virus vaccine given subcutaneous for adults more than 14 years.
* Hepatitis A virus attenuated vaccine given I.M as two doses.
* Typhoid splito vaccine given every 3 years.
Pharmacoeconomics
Pharmacoeconomics can be defined as the measurement of both the cost and
consequence of therapeutic decision making. It provides a guide for decision-makers
on resources allocation but doesn’t offer a basis on which decision should be made.
pjarmacoeconomics can assist in planning process and help assign priorities where,
for example , medicine with a worse out come may be available at a lower cost and
medicine with better outcome and higher cost can be compared.
Types of health economic evaluations
Cost- benefit analysis (CBA)
Consequence are measured in terms of the total cost associated with a program both
costs and consequence are measured in monetary terms this type is preferred by
economists, its employment in health care is problematical as it is frequently difficult
to ascribe pecuniary values to clinical outcomes such as pain relief, avoidance of
stroke or improvements in quality of life.
Cost- effectiveness analysis ( CEA)
It is described as examination of the costs of 2 or more programs, which have the
same clinical outcomes as measured in physical units. Treatment with dissimilar
outcomes can also be analyzed by this technique.
16
Cost of different drugs used in paediatric
drug
Aspirin
Bricanyl
Mucosolvan
Defalgan
Trixone
Ventoline
Gentamycin
Lasix
Lanoxin
Decadron
Ciprobay
Augmantin
Metrolag
Bactrim
Phenargan
price (DH)
3.5
19.5
12.5
6.5 – 7 – 8
1g =89 - 0.5g = 53
32.5
6
26
12
15
185 – 123 - 62.5
120
54
30
9
Drug
Predialyte
Zithromax
Zinacef
Klacid
Prednisolone
Cephalexin
Rocephin
Voltaren
Calpol
Kiddi pharmaton
Amoxidine
Zinnat
Brufen
Benylin
Adol
17
price (DH)
6.5
96.5 - 55.5
110
94 –91 -75.5
43
46
34.5 - 54-99.5
46
9
18.5
37
65 - 73.5 -125
11.5-21-30.5
8
7
CASE: 1 ACHILD WITH FEVER
Clinical presentation:
T.R is active 4-year old. , He has six cats. Few days ago, T.R right jaw was little bit
swollen and he has also seemed a little warm and he took Tylenol and seemed to feel
better. The next day he didn’t eating as much the last few days and he’s seemed kind
of tired.
The following morning he went to the hospital and his neck was more swollen, he
also had a little rash on his bottom which spread and he was getting pretty irritable.
His father took him to the emergency room and he had a fever. They gave him some
antibiotics but that didn’t seem to help. Pediatrician saw him and he was worried
about him having swollen neck, fever had rash.
Patient details
Name: T.R, sex: male, age: four, height: 75th percentile of age, weight:
>95percentile.
Case history
Tanner nose had nasal crusting, he had dry erythematous, cracked lips, slightly
enlarged tonsils that were erythematous and he had elevation of the tongue papillae.
His neck was supple but had a 4-cm right anterior cervical node, which was tender.
He had no other adenopathy.
Symptoms
* Fever (elevation of body temperature above, greater than 39.5 ˚ c) .
* Swollen neck and tender.
* Rash over his entire body, but especially in the upper extremities and groin area.
Signs
T: 37˚c, pulse: 132, BP: 98/45
Laboratory test
* His CBC showed Hgb=13 g/dl, Hct=37%.
* Platelet count=333 K/mm3.
*WBC=18.1 K/mm3 with 88% PMNs, 2% bands, and 5% lymphocytes.
* Urinalysis showed specific gravity=1.005, pH=6.0 and a positive leukocyte esterase.
*Microscopic urinalysis showed 15-19 WBC/hpf and no RBCs.
18
A general screen showed normal electrolytes, BUN and Creatinine but a slightly
elevated GGT, ALT and total bilirubin. A blood culture and urine culture showed no
growth after 7 days. An EKG was normal.
Imaging findings
Pediatric Cardiology's echocardiogram showed normal coronary arteries and normal
atrial and ventricular function.
Diagnosis
He had Kawasaki disease which associated with fever, conjunctival infection, mouth
and lip changes, swelling and erythema of the hands and feet, rash, lymphadenopathy,
aseptic meningitis, diarrhea or hepatic dysfunction.
* Diagnostic criteria for Kawasaki Disease are:
-Fever of at least 5 days duration
-Presence of 4 of the following 5 conditions:
- Bilateral conjunctival infection.
- Changes in the mucosa of the oropharynx, including dry cracked lips or
strawberry tongue.
- Changes of the peripheral extremities, such as edema or erythema of
hands or feet .
- Truncal rash, nonvesicular, maculo-papular.
- Cervical lymphadenopathy .
Treatment Course, Prognosis and Follow-up
*
Tanner was given intravenous immunoglobulin (IVIG), aspirin and will follow up
with his local physician for a physical exam, CBC and differential. He will return to
cardiology clinic in 4-6 weeks for a follow-up echocardiogram. He was also given
anti-pyretics.
* Acute management of Kawasaki Disease includes the use of IVIG and
anticoagulants such as aspirin and/or Coumadin.
The American Heart Association committee guidelines for long term follow-up and
management are based upon the degree of coronary artery involvement. Management
includes anticoagulants, especially anti-platelet medications such as aspirin. It is
recommended to discontinue the use of aspirin with influenza illness and with
Varicella vaccine administration because of the risk of Reye's Syndrome. Influenza
Vaccine should also be considered for these patients. Testing may include repeated
echocardiography, electrocardiogram, stress testing and angiography.
19
*Aspirin (acetyl salicylic acid)
Indication
- Effective relief of mild to moderate pain and inflammation.
- Reduction of fever.
-Prevention of heart attack.
- Prevention of stroke.
- Prevention of colon cancer.
Dosage form
-
Capsule, enteric coated 500 mg.
Capsule, enteric coated granules 325 mg.
Gum tablets – 227 mg.
Suppositories- 60 mg, 125 mg, 130 mg, 195 mg, 200 mg, 300 mg, 325 mg,
500mg, 600 mg, 650 mg , 1.2 grams.
Tablets-65 mg , 81 mg, 325 mg, 500 mg ,.
Tablets, chewable- 81 mg .
Tablets prolonged action 650-800 mg .
Precaution for use by infants and children: Reye’s syndrom ( brain and liver damage
in children, often fatal ) can follow flu or chicken pox in children and teenagers.
-
Usual dosage schedule for children
Up to 2 years of age – consult physician.
2-4 years of age- 160 / 4 hrs , up to 5 doses / 24 hrs.
4-6 years of age – 240/ 4 hrs, up to 5 doses/ 24 hrs.
6-9 years of age- 320/ 4hrs, up to 5 doses/ 24 hrs.
9-11 years of age- 400/4hrs, up to 5 doses/ 24hrs.
11-12 years of age – 480/ 4hrs, up to 5 doses/ 24hrs.
Drug interaction
-
Aspirin may increase the effect of oral anticoagulants, insulin, heparin,
valporic acid.
Aspirin may decrease the effect of β- blockers, captopril, furosemide,
NSAIDS.
Antacid, cimitidine, acetazolamide increase the effect of aspirin.
Side effects
Dependence, anemia due to chronic blood loss from erosion of stomach lining,
development of stomach ulcer, aspirin allergy, asthma, kidney damage, and prolonged
bleeding time.
Contra indication: allergic reaction to aspirin, bleeding disorder, peptic ulcer, 3
months of pr
20
Comment on treatment
- Intravenous gammaglobulin (IVIG) given before the 10 day of the illness has
reduced the morbidity of Kawasaki Disease and the coronary artery aneurysms
from 25% to 5% (6-8 weeks after the initiation of therapy). In most patients,
coronary artery aneurysms regress within two years of the illness. Approximately
1% of patients who recover from Kawasaki Disease or who develop giant
aneurysms go on to have coronary artery destruction. A rare complication is
peripheral ischemia, which can cause gangrene.
- Reye’s syndrome. Owing to an association with Reye’s syndrome the CSM has
recommended that aspirin containing preparation should no longer be given to
children the age under 2 years, unless specifically indicated.( aspirin cause liver
damage and encephalopathy) e.g. juvenile arthritis ( still disease) it is important to
advise families that aspirin is not a suitable medicine for children with minor
illness.
21
CASE: 2 A CHILD WITH PNEUMONIA AND HEART FAIULRE
Clinical presentation
D.K is 8 months- old. She had water in lung since her birthday (16/5/2000) and
Doctors prescribed antibiotics course injection.
After several months (8) on 13/2/ 2001 she was admitted to NMC hospital with fever,
wheezing, and chest distress and diagnosed as retro cardiac pnumonities, bronchial
vascular congestion.
Patient details
Name: D.K, sex: male, age: 8 months- old, height: 70 cm, weight: 7 kg.,
Case history
D.K had water in lung since her birthday.
Symptoms and signs
-
Fever; pain in chest, chest distress at eating and wheezing.
T: 38.5 ˚ c, Respiratory Rate: 80/ mt , SPO2 : 92%, Pulse: 126/min.
Investigation
-
-
Heart exam showed a regular rate and rhythm.left retro-cardiac pneumonitis
with signifacant vascual congestion in lung.
Abdominal examination was normal and CNS exam was normal.
On Chest x – ray lung not clean and pulmonary odema also present due to
infection.soft tissue and visualized bony rib are normal. adense homogenous
opacity is observed in the retro-cardiac region on the left side. The rest of the
visualized lung fields show prominent vascular markings .the pleural spaces are
free. Domes of diaphragms are normal. Cardiac size and ventricular configuration
are normal impression.
Bacterial culture done for antibiotic therapy.
PO2, PCO2, PH , HCO3 we re done.
22
SPO2
pulse
92%
90%
96%
91%
93%
91%
93%
91%
62%
94%
91%
94%
93%
85%
126/min
161/min
145/min
136/min
137/min
139/min
150/min
169/min
144/min
140/min
140/min
165/min
150/min
146/min
Diagnosis
Retro -cardiac pnumonities , bronchial vascular congestion.
Treatment
-
Bricanyl 1.5 TDS ,Mucosolvan : 2.5BD , Trixone: 250 mg IM , Defalgan
(Suppositories), Nebulizer given for 15 min., 2ml of Saline, Ventoline solution 20
units.
* Bricanyl
Indication
Very effective relief of bronchospasm , stop premature labor, idiopathic
urticaria.Dosage form Aerosol 0.2 mg, injection 1 mg/ ml, tablet 2.5 mg and 5 mg,
syrup 0.3 mg /ml. Interaction Bricanyl interact with epinephrine, diabetes,
hyperthyroidism, digitalis, hypokalemia and steroid. Side effects Dryness, irritation of
mouth, nervousness, tremor, palpitation . Contraindication Diabetes, hypersensitivity
to any of the ingredient.
* Mucosolvan
Indication Used in emphysema, bronchitis, and chronic inflammation pulmonary
.Dosage form Tablet 4.5 / 8 mg, solution 2 mg /ml, inhalation and ampoules 4 mg/ 2
ml. Side effects Occasiord GI , increase flow of secretion. Contra indication Gastric
ulcer Other competitors Bisolvan
* Defalgan
Indication Relief of pain and fever. Dosage form Suppositories.Contra indication
Hyper sensitive to paracetamol, hepato- cellular insufficiency. Other competitors
ADOL.
23
* Trixone
Indication Used in sepsis, meningitis, abdominal infection, infection of bones,
joints, infection in patient with impaired defence, renal, and upper respiratory tract
infection. Dosage form Ig IV, Ig IM, 0.25 IM, and 0.5 IV, 0.25 g IV, 0.5 IM.
Interaction Increase renal toxicity of aminoglycoside, elimination of ceftrixone is
not altered by probenecid Side effects Loose stools leukepenia, allergic dermatitis,
dizziness and increase liver enzymes. Contraindication Patient with
hypersensitivity to cephalosporin, allergic cross- reaction, pregnancy and lactation.
Other competitors Rocephin
The problem
After one month, D.K had fever for several days again so she went toHospital. There
doctors said that she was given small dose of antibiotic course which is 350 mg, but it
should be 700 mg so the infection return back in more complicated case.
An immediate drip of Dextrose 5 % was given to the patient.
.
Investigation
-
Chest x-ray was done and pulmonary odema was found.
On heart examination, cardiomegaly was found due to lung disease and heart
works against high resistance.
Echocardiogram.
Treatment
At the first 2days no effect for gentamycin so, doctors increase the dose , then give
her lasix due to odema ( pulmonary and peripherally ) .
Digoxin was given orally to increase force of contraction of the heart due to its +ve
inotropic effect .Decadron used as anti-inflammatory.
* Gentamycin
Indication Septicaemia and neonatal sepsis, meningitis and other CNS infection
,biliary – tract infection , acute pyelonephritis or prostatitis, endocarditis, pnumonia in
hospital patients ,adjunct in listeral meningitis. Caution Pregnancy ,renal impairment,
infants and elderly. Contra indication Myasthenia gravis. Side effect Vestibular and
auditory damage. nephrotoxicity ,hypomagnesemia on prolonged therapy ,vomiting ,
nausea. Dosage form By IM or IV injection over at least 3 min or by IV infusion, 2-5
mg/kg daily (individual doses every 8 hrs)
Child up to weeks, 3mg/kg every 12 hrs, 2weeks-12 years, 2 mg / kg every 8 hrs.
By intrathecal inj, seek specialist advice, 1 mg daily (increase if necessary to 5 mg
daily) Drug interaction Increase nephrotoxicity with colistin. , Increase risk of
ototoxicity with vancomycin., Increase risk of ototoxicity with diuretics.
24
* Lasix
Indication Loop diuretics are used in pulmonary oedema due to LVF , IV
administration produces relief of bearthlessness and decrease pre-load sooner that
would be expected from the time of onset of diuresis .they are also used in pt with
long standing heart failure .also used in oedema, oliguria due to renal failure. Dosage
form Tablet 40mg, IM 20-50 mg .IV, IV Infusion 250mg over 1 hr Drug interaction
Increase hypokalemia with K sparing diuretics . Increase nephrotoxicity of NSAID’S.,
Decrease absorption of thiazide., Increase ototoxicity of aminoglycosides., Increase
risk of posural hypotension.
Side effect
Hyponatraemia,hypomagnesaemia,hypokalemai,hyperuricaemia,GITdisterbanc,hyper
glycemia,increase cholesterol level ,pancreatitis and renal impairment.
Contraindication
Liver cirrhosis, renal failure and anuria.
* Digoxin ( lanoxin)
Indication
Used in the management of chronic cardiac failure and in ventricular dilation. Also
used in atrial fibrillation and supra-ventricular arrythmia particularly atrial flutter to
decrease ventricualr rate.
Dosage and administration
Orally 1-1.5 mg in divided doses over 24 hrs, maintenance dose is 62.5-500
microgram. According to renal function. Emergency loading dose by IV infusion total
dose is 0.5-1 mg.
Contraindication
In heart block, arrythmia caused by digoxin intoxication.
Drug interaction
These may rise the renal excretion, tissue binding, plasma protein binding and
distribution within the body. Agents causing hypokalemia increase sensitivity to
lanoxin.like diuretics. digoxin level may increase with amidronee, captopril ,prazocin
and tetracycline.
Digoxin level may decrease with antacid, bulk laxative, diphenoxylate, phynitoin,
rifampicin.
Calcium channel blockers cause no change in serum level of digoxin.
25
Adverse reaction
Anorexia, nausea, vomiting, diarrhea, gynaecomastia, weakness, fatigue, headache,
visual disturbance, intestinal ishaemia, skin rashes, and thrombocytopenia.
* Decadron ( dexamethasone)
Indication
Condition where the inflammatory and immunosuppressive effects of the corticoid are
desirable, especially for intensive treatment during shorter period .
Dosage and administration
General recommendation for oral administration:
Dosage requirements are variable and must be individualized according to the disease
and the response of the patient .the usual initial dose varies from 0.7 to 15 mg a day
depending on the disease being treated ( for infant and children the dose has to be
reduced ) .
Contra-indication
Systemic fungal infection , hypersensitivity to any component to this drug,
administration of live virus vaccines.
Drug interaction
* Acetyl salisylic acid should be used cautiously in conjunction with corticosteroids in
hypoprothrombobinemia.
* Diphenylhydantion and rifampicin may enhance the metabolic clearance of
corticosteroid ,resulting in decrease blood level and physiological activity these
interaction may interfer with dexamethasone suppression tests , which should be
interpreted with caution during administration of these drugs .
* Hypokalemia observed with diuretic.
Corticosteroids may affect the nitroblue tetrazolium test for bacterial infection and
produce false negative results.
Side effects
Sodium retention, fluid retention, congestive heart failure, potassium loss, muscle
weakness, steroid myopathy, loss of muscle mass, peptic ulcer, abdominal distention,
impaired wound healing, erythma, increase sweating, convulsion, increase intracranial
pressure, nausea, vomiting, hiccups, glaucoma, and malaise.
26
Comment
In this case the water inside lung lead to obstructive lung disease and this disorder by
long lasting over load of the heart muscle working against resistance to out flow, lead
to heart failure.
The symptoms associated with failure include increased venous congestion and
peripheral oedema. So drugs used to decrease these symptoms. And the current
strategy is to try to preserve the myocardium. The objectives are to improve
functional capacity and to increase survival.
-
Doctors used loop diuretics to increase water and Na excretion to decrease oedema .
* Lasix should be used with caution with:
Digoxin due to hypokalemia may occur and lead to toxicity.
With triaxone it increase ototoxicity of cephalosporine.
With Decadron it increase risk of hypokalemia and antagonized diuretic effect.
-
* Digoxin
-Antibacterial enhances effect of digoxin.
With corticosteroid increase effect of hypokalemia.
-
* gentamycin
Increase risk of nephrotoxicity with cephallosporin.
-
* bricanyl
With corticosteroid it increase risk of hypokalemia if high doses taken.
With diuretc it increase risk of hypokalemia.
So we have to decrease demand of heart by bed rest, reduction in physical activity. A
sodium-restricted diet should be introduced and use of medicines should be carefully
reviewed. Care should be with salt substitutes, which may contain considerable
amounts of potassium. Those could lead to problems if potassium supplements or
potassium sparing diuretic are used at the same time.
CASE: 3 ACHILD WITH VOMITING
27
Clinical presentation
JAMIE is 3 days old. His mother fed him with bottle after he was born, he threw up
.she thought may be he swallowed a lot of phlegm. The next few times she fed him on
Thursday, everything came right back up. He started getting a little better at keeping
his food down late Thursday. On Friday, when she got released, the pediatrician told
her Jamie would have to stay another day. If the vomiting slowed down, Jamie could
come home Saturday. The pediatrician told her she was probably feeding Jamie too
much, but she doesn’t think that. On Friday night and Saturday morning Jamie was
still vomiting a lot of bright greenish-yellow fluid. At this point the pediatrician
ordered x-rays.
Patient details
Name: Jamie, sex: male, age: 3days-old, weight: 2780 gm.
Case history
Jamie was vomiting a lot of bright greenish –yellow fluid since he was born. He is
with bilious emesis.
Symptoms and signs
Vomiting, and stable vital sings.
Investigation
* His abdominal evaluation showed a soft, non-tender, non-distended abdomen
with good bowel sounds. There were no masses and no hepatosplenomegaly.
* Genitourinary examination showed a circumcised male with bilateral descended
testes and no hernias noted.
* The rest of his physical examination was normal.
Clinical labs
-CBC differential was unremarkable.
-His electrolytes were Na=144 mEq/l, K=3.5 mEq/l, Cl=107 mEq/l, CO2=23 mEq/l ,
BUN=6 mg/dl, Creatinine=0.8 mg/dl and Glucose=78 mg/dl (within normal limits for
age).
-Total bilirubin was 5.1 mg/dl and direct bilirubin was 0.6 mg/dl (within normal
limits).
Imaging findings
Abdominal radiograph was unremarkable. An upper GI series showed that the
duodenal-jejunal junction was abnormally located to the right of the spine. At this
point, there was an abrupt narrowing of the duodenum with a fine thread of contrast
extending inferiorly in a "corkscrew"-like appearance. Abdominal ultrasound with
28
color Doppler showed the superior mesenteric vein coursing around the superior
mesenteric artery with a swirl-like appearance.
Diagnosis
Malrotation with midgut volvulus resulting in partial small bowel obstruction.
* malrotation with midgut volvulus is a newborn <1 month old with bilious
vomiting. However, malrotation with midgut volvulus may present as intermittent
abdominal pain and/or vomiting. Malrotation is also associated with other
congenital anomalies such as diaphragmatic hernia, omphalocele and
gastroschisis. It is the failure of the developing bowel to undergo the usual
counterclockwise rotation in the 4th to 10th week of embryogenesis.
* Volvulus refers to complete twisting of a loop of bowel around its mesenteric
attachment, which results in intestinal obstruction. The superior mesenteric artery
can be compressed leading to ischemia of its distribution, the small bowel from
the duodenal-jejunal junction to mid-transverse.
Treatment course, prognosis and following up
Malrotation with midgut volvulus is a surgical emergency, because ischemia can lead
to small bowel infarction. Doctor removed Jamie's appendix. And said it was on the
wrong side.
Doctor gave him after recovery from the operation, Ciprobay 10mg 3 times daily,
Metrolag injection 250mg, Augmantin injection 60 mg and IV fluid 5 % dextrose.
* ciprobay
Dose in children is 8-16 mg/kg daily in 2 divided dose. ciprofolxacin should be used
with caution in children. It causes arthropathy in the weight- bearing joints so shortterm use of a quinolone in children may be justified. At the first singes of pain or
inflammation patient-taking drug should discontinue.
* Augmantin
Dose in children 25mg/kg every 8 hrs. It might lead to cholestatic jaundice so used
with caution.
* metrolag
The dose for a child is 7.5 mg/kg every 8 hrs.it is used as surgical prophylaxis and for
treatment of anaerobic bacteria.
Comment
29
Malrotation with midgut volvulus is a surgical emergency, because ischemia can lead
to small bowel infarction. To relieve the obstruction, the peritoneal bands (also known
as Ladd bands) around the duodenum are divided. The colon is placed on the left and
the duodenum on the right to broaden the mesentery. An appendectomy is performed
to avoid future confusion if the child has abdominal pain.
A complete history should be taken from the patient and/or family. Attention should
be paid to the timing of the emesis in association with eating, any associated pain or
discomfort, changes in eating and elimination patterns, whether eating or eliminating
improves or worsens the emesis, characteristics of the stool and urine, any trauma or
systemic problems such as changes in mentation or weight loss, and fever.
The physical examination should emphasize the abdominal examination, but other
areas such as the respiratory, and genitourinary systems should be closely examined.
Additionally, other systemic signs should be looked for including skin changes and an
erythematous pharynx.
A careful history and physical examination guides all laboratory and radiographic
evaluations. Depending on the age of the patient and the differential diagnosis,
radiographic procedures such as plain films, ultrasound and contrast studies may be
ordered and help elucidate anatomic problems. If a surgical problem is being
considered, then early consultation with a surgeon should be considered.
Evaluation
Laboratory evaluation helps to find systemic and infectious diseases and can help
determine secondary problems such as electrolyte abnormalities caused by copious
emesis.
The effects of some drugs can be influenced by simultaneous of other drugs.
That Metrolag with Antibacterial accelerates metabolism of anti -fungal agent and so
decrease the plasma concentration.
30
CASE 4: A CRANKY CHILD
Clinical presentation
D.A is 9 month-old. He is active kid. Last week his parent noticed that D.A was
pulling his ear, especially the right one .his father took him to pediatrics clinic.
Patient details
Name: D.A, sex: male, age: 9 month old, height: 79 cm, weight: 9 kg.
Symptoms and signs
* Fever
* Recent onset of irritability, pulling of ear and ear pain
* Anorexia
* Vomiting or diarrhea
His temperature was 37.9 C and his other vital signs were normal.
Clinical Physical Exam
His right ear exam showed the tympanic membrane to be erythematous with fluid
behind the membrane and poor movement.
His left tympanic membrane revealed normal landmarks but had slightly decreased
movement. His nose exam showed minor mild erythema with clear to yellow nasal
discharge. The rest of his physical examination was normal.
** Lab tests are usually not necessary in the diagnosis of acute otitis media.
Tympanocentesis is indicated in the following cases:
* Acute otitis media with poor response to antibiotics
* Supportive complications from acute otitis media
* Acute otitis media in a newborn or child with primary or secondary
immunodeficiency
* A child who is acutely ill/septic ,Blood cultures are rarely helpful.
Diagnosis
The diagnosis for a 9-month-old with fussiness, fever and pulling of his ear is Otitis
media.
** Otitis media in small children can present with a simple history of fussiness with
or without fever. Onset of pain, associated fever, sore throat, rash, rhinorrhea, and
swelling of the head or neck should be discussed. The location and intensity of the
pain can be difficult to discern in young children. Pulling of the ears is a common
complaint heard from parents but this does not correlate with disease. Obvious causes
such as trauma or foreign body insertion should also be discussed. A history of
tinnitus or vertigo often can be obtained from older children.
The head and neck examination is the area of interest. The head and neck should be
examined for lymphadenopathy and skin changes. The nose should be examined for
31
rhinorrhea, and pharynx for erythema, exudates and dental abnormalities the external
examination of the ear should look for pinna position and otorrhea. The tympanic
membranes are generally reddened with increased vascular markings, the normal
landmarks are distorted with bulging of the membrane and loss of the light reflex.
Pneumatic otoscopy reveals an immobile tympanic membrane, and if tympanometry
is available would show a flattened curve.
Diagnosis is made by pneumatic otoscopy, examining the tympanic membrane for
position, color, and degree of translucency and mobility.
Characteristic of acute otitis media is an opaque tympanic membrane with a bulging
contour, obscured landmarks, with limited or no mobility. A tympanogram may be
obtained to assess mobility. Erythema of the eardrum is common.
Middle ear effusion is a frequently associated finding but asymptomatic in it self.
Otitis media with effusion will reveal air-fluid levels, serous middle ear fluid, and a
translucent tympanic membrane with decreased mobility associated with negative
pressure in the middle ear.
Treatment Course, Prognosis and Follow-up
Treatment of simple, uncomplicated otitis media is a 7-10 day course of antibiotics
against the most common organisms (e.g. Strep. pneumonia, Moraxella catarrhalis,
and Haemophilus influenza). Follow-up examination to document the resolution of
the infection is generally advocated; the timing depends on the age of the child.
* Damon was treated with a 10-day course of oral Bactrim (trimethoprim/sulfa)
which he took without problems and had resolution of his symptoms by day 3. At a 21/2 week follow-up visit, Damon's ear examination had returned to normal.
* Bactrim
Indication
It is used in urinary tract infrction, acute and chronic bronchitis, pneumocytsis carinii
pneumonia, toxoplasmosis and nocardiasis, and acute otitis media in children when
there is good reason to prefer it.
Caution
Renal impairment, breast feeding, predisposition to folate deficiency, manufacturer
recommended blood counts on long term therapy .
Contra indication
Sever renal impairment, pregnancy, and blood disorders.
Side effects
Diarrhea, necrosis, convulsion, vertigo, dizziness, cough, anorexia, depression,
ataxia, megaloplastic anaemia, renal disorder, and liver damage.
32
Dosage form
By mouth 960mg every 12 hrs, child every 12 hrs, 6 weeks, 5months, 120 mg;
6months-5 years, 240 mg ; 6-12 years,480 mg
By IV infusion, 36-mg/kg daily in 2 divided doses to 54-mg/kg daily in sever
infection.
Drug interaction
Increase plasma concentration of procainamide
Enhance the effect of acenocoumarol and warfarin
Increase plasma concentration of phenytoin and antiviral effect.
Comment
Ear pain or otalgia is one of the most common problems in childhood. For parents and
many health care providers ear pain equals otitis media, but there can be other causes
and providers must always perform a careful history and physical examination.
Most cases of otitis media occur in the under-6 age group. The reasons for this are
based on changes in the immune system and the anatomy of the Eustachian tube. The
angle of the tube changes from 10 degrees to 45 degrees from infancy to adulthood,
and lengthens from 18-35 mm. Therefore, children generally have functional
improvement with age. Other factors that contribute to Eustachian tube dysfunction
are allergies and seasonal changes. Two common agents that have been identified are
Strep. pneumoniae and Haemophilus influenzae.
33
CASE 5 : A CHILD WITH ANAPHYLACTIC SHOCK
Patient details
Name: O.M, sex: male, age: 9 months, his weight: 8kg, his height: 80 cm
Past medical history
When he was 40 days he was admitted to the hospital of emergency accident unit
(E/A unit) complaining of dyspnoea, rash and fever .the doctor diagnose the case as
anaphylactic shock. O.M took fenestil drops adrenaline injection and antihistamine
injection. The following the antihistamine he got vomiting so they stop antihistamine
Signs and symptoms
Rash, fever the temperature was 39 ْc, and dyspnoea. SPO2 was 85%
Diagnosis
Anaphylactic shock.
Treatment
He was given adrenaline IV, antihistamine IV and oxygen applied as mask.
Comment
The best treatment is prevention. Children with known allergies should be protected
from causative antigens, if substances generally known to cause anaphylaxis are
administered in the office or clinic, the child should be watched for 20 min or before
he leaves the area. Equipment and medications needed to treatment anaphylaxis
should be readily available.
Certain foods, including eggs, fish, cow’s milk and bee stings may precipitate
anaphylaxis shock.
Immediate therapy includes the administration of 0.01 mg/kg of aqueous Ad (1:1,000)
subcutaneous if child in shock 1-2ml of 1:10,000 aqueous Ad should were injected IV
also oxygen should be administered by mask. Antihistamine, which is Benadryl, can
be given after the child has responded but in this case it was stopped because of its
side effect which is vomiting. Hydrocortisone 10 mg/kg given IV initially may
decrease the duration of episode.
Some patients with sever allergy to insect stings or food are encouraged to carry prefilled adrenaline syringes for self administration during the period of risk
34
CASE: 6 TWINS WITH ABDOMINAL INFECTION
Patient details
Name: Sara, sex: female, age: 2years, height: 100cm, weight: 15 kg
Name: Mohammed, sex: male, age: 2years,height: 100cm,weight: 16kg
Past case history
Sara and Mohammed are twins. They were admitted to hospital complaining of fever
wheezing vomiting and cough. They were given primperam injection, phenargan
injection and ventolin applied as inhaler. Mohammed took a drip of ringer lactate
Signs and symptoms
Diarrhea, gastroenteritis, fever T was 36ْc, abdominal pain, cold, cough, rash,
vomiting, and wheezing.
Laboratory test
HB was 12.7, WBC count is 12.4 (4-11), neutrophils34% (40-75), Monocytes1% (210), esoniphils 5% (1-6%) and basophils 0 (<1).
Diagnosis
Acute abdominal infection.
Treatment
Doctor prescribes for them primperam injection and phenargan injection.and
predialyte electrolytes for maintenance.
Comment
Vomiting lead to dehydration and complication of loosing fluid and electrolyte is
hypokalemia which lead to acetone urine and death. So we have to take of vomiting
and diarrhea so we give glucose and kcl inJ.
Solutions of electrolytes are given intravenously, to meet normal fluid and electrolyte
requirements or to meet replenish substantial deficits or continuing losses, when the
patient is nauseated or vomiting and is unable to take adequate amounts by mouth.
When IV administration is not possible large volumes of fluid can be also given SC
by hypodermoclysis.
In individual patient the nature and sverity of the electrolyte imbalance must be
assessed from the examination.
35
CASE: 7 ACHILD WITH ASHTMA
Patient details
Name: S.M, Sex: male, Age: 11 years, height:`139 CM weight:30
Case history
S.M 11 years old male child admitted to hospital complaining from fever and dyspnea
which was started since 2 days. He had history of asthma in his childhood but without
any problem in the last 3 years.
He was seen by some emergency physician and treatment started with I.V
corticosteroid and solmetrol under coverage of antibiotics.
Signs and symptoms
* Fever, wheezing, dyspnea, pain at chest,
* T: 39 ْc, respiratory rate (R.R)= 80/min, pulse = 125/min, B.P = 110/70
Investigation
-
-
* Chest x-rays
Normal expansion of pulmonary pharnchyma. Brnchopranchymal
inflammatory infiltrate are noted at both hilar and perihilar regions and the RT.
Lower field of the chest.
No mass lesion.
Both pleural spaces are clear.
The heart is normal in size.
* Hematological test
-
H.b = 12.4 g/dl ( 14- 18) , heamatocrit = 37% ( 40 –54 ), RBC = 4.6 ml / mm3
( 4.6 – 6.2 ), WBC = 12,500 / mm3 ( 4000- 1000) and normal leukocyte.
* Urine examination.
* nasopharynx x –ray which is unmarkable.
* unmarkable P.N.S x ray for suggestive signs of R.T maximally sinusitis.
Diagnosis
Asthma and bronchpneumonia.
36
Treatment
He was admitted with diagnosis o asthma exacerbation and pulmonary infection and
treatment started with IV corticosteroid ( hydrocortisone 150 mg B.D ) , solmatrol,
zithromax 500 mg OD orally , zinacef 500 mg BD IV .
He shows improvement since the second day so corticosteroid changed to oral
prednisolone 5 g OD orally beside inhaler and after that he dicharged under treatment
with oral prednisolne, servant and klacid 250 mg .
Drug interaction
corticosteroid with solmatrol ( beta 2 agonist) will increase in risk of hypokalemia.
Corticosteroid with antibacterial will accelerate metabolism of corticosteroid so
decrease its effect.
Comment
Doses of hydrocortisone given with caution during administration of solmatrol due to
increase in risk of hypokalemia.
Patient with sever or life- threading attacks may not be distressed and may not have
all these abnormalities; the presence of any should alert doctor
Failure to respond adequately at any time requires immediate referral to hospital.
37
CASE: (8) A CHILD WITH ACUTE HEMATOGENOUS
OSTEOMYELITIS
Patient details
Name: Y.K, Sex: male, Age: 9 month-old, height: 90cm, weight: 10kg
Case history
Y.S, 9-month-old male child had normal growth. The mother noted a fever of
unknown origin for the previous 2 days with vague abdominal pain and diarrhea.The
infant was admitted with a diagnosis of viral infection vs. mycoplasma pneumonia.
Started on erythromycin.

Hospital Day 2: Right hip was noted to be flexed and orthopaedic services
consulted. The right hip was aspirated, Gram stain: G PC, Started on Nafcillin
150mg IV q4. The child than had daily hip aspirations for decompression.
Final culture: coag (+) Staph aureus resistant to PCN.
- Hospital Day 6: Respiked to 103.4. R hip Xray showed a defect in proximal
medial metaphysis, Possible osteomyelitis. The child was than taken to the
operating room for Incision & Drainage of Right hip via anterolateral approach
with suction irrigation system (seropurulent fluid drained).
- Post Operative Day 7: Drains removed. Respiked to 101.6. R hip Xray:
suggestion of demineralization of proximal metaphysis. The hip was reaspirated
and pus was obtained. Cultures neg.
- Post Operative Day 12: Respiked to 103.6. Gentamicin 1 mg IV q6 added to
Nafcillin. Daily aspirations of 10 cc purulent fluid, all cultures neg.
- Post Operative Day 18: R hip Xray: subluxation of R hip, possible metaphyseal
lucency consistent with osteomyelitis. Taken to OR for repeat I & D of R hip via
posterior approach with Penrose drains and hip spica cast (15cc seropurulent fluid
drained). Antibiotics changed to Oxacillin 225mg IV q4.
- Post Operative Day 7: Drains removed. Afebrile.
- Post Operative Day 9: Afebrile for 48hrs. Transferred to AI duPont Institute.
Initial labs: WBC 15,100, ESR 72. R hip Xray: changes in proximal . metaphysis
including lucency and demineralization, hip subluxated. Treated with oxacillin
and Pavlik harness.
- Hospital Day 12: WBC 12,600, ESR 48. Discharged home in Pavlik harness x 1
yr., Oxacillin 250mg po q4.
2 month Office Follow Up: Rt hip Xray: progressive destruction of capital femoral
epiphysis, cystic changes in metaphysis consistent with AVN.
Investigation
- WBC not invariably elevated (Scott et al: 41 % had WBC < 10,500).
- ESR elevated in majority of cases (not reliable in neonates, patients with sickle
cell anemia, lags behind clinical improvement).
- C-reactive protein (Unkila-Kallio et al: elevated in 98% of cases, peak level on
day 2, normal within a week of treatment).
38













- Blood cultures positive in 40 - 50% of cases.
* XRAY:
Early: deep soft tissue swelling only.
Bone changes usually not present until > 1 week.
Bone scans: Technetium-99m useful for localization in spine and pelvis,
detecting multiple sites of involvement.
Not accurate in very early cases (< 24 hrs).
Non specific (trauma, tumor, infection).
False negative rate 4 - 20%.
Bone aspiration does not affect results of bone scan if bone scan obtained
within 48 hrs after aspiration (Canale et al).
* MRI:
Sensitivity = bone scan
Specificity > bone scan
* ASPIRATION:
Most valuable clinical test. Positive in 85-90% of cases.
Neonates: group B Strop > Staph aureus
Infants & children: Staph aureus (90% of cases)
H. influenzae (6mo - 4yr)
Sickle cell disease: Staph aureus > Salmonella
Treatment
Infants and children ( S aureus (90% of cases) ) are given Oxacillin, lz-)o mg/kg for
24 hr


Duration of antibiotics: 6 weeks
Switch from IV to oral antibiotics once clinical response is seen (7 - 1 0 days).
Usual oral antibiotics: Dicioxacillin 50 mg/kg over 24 hr or Cephalexin 150 mg/kg
over 24 hr
90% response rate to antibiotics alone when treatment is initiated within first few days
after onset of symptoms.
SURGICAL INDICATIONS:
aspiration of pus (ie. abcess) sequestra in chronic osteomyelitis joint sepsis
delayed clinical response to antibiotics(> 36 hr)
Comment
Neonatal Osteomyelitis
Metaphyseal vessels penetrate directly into chondroepiphysis up to 12 - 18 mo.
Infections starting in metaphysis readily spread to chondroepiphysis and joint.
Multiple sites involved in 40% (immature immune system).
This case is an example of untreated septic arthritis which caused avascular necrosis
of the proximal femur. The primary cause of this is undrained septic hip. Repeated
aspiration is not adequect treatment of a septic hip.
CASE: (9) A CHILD WITH PNUEMONIA
39
Patient details
Name: F.Z, sex: male, Age: 2.5 years old, weight: 12kg, height: 90cm
Case history
F.Z is male, 2.5 years old, Australian, he was admitted to hospital complaining of rise
in temperature, rapid respiration and cough. At first cough was dry and painful but
later it becomes blood stained sputum. No vomiting. Diagnosis is made by
examination of sputum sample preferably obtained by deep expectoration.
Sings and symptoms
* Fever (T=38.9ْ c), dypneoa, cough (at first it is dry and painful but later
haemoptasis), no vomiting, pain at chest.
Laboratory tests
* Chest x- ray usually show sings of consolidation in the middle and lower zones but
radiological changes lag behind the clinical course of the disease.
* Stool analysis: color: yellowish, consistency: semi- formed
* Hematological tests: HB= 8.9, WBC=20.3 (4-11), RBC= 3.5 (4.6-6.2), platlet=385
(150-450), MCV=72 (80-96), MCH= 26 (26-32), neutrophils = 86% (40-75),
lyphocytes= 13% (20-45), monocytes= 1% (2-10), eosinophils= 0 (1-6), basophils
= 0(0-1).
* Urea, serum 43(17-50) retrovirus in urine (latex test)
* Blood electrolyte test: Na 133 (135-146), Cl 98 (95-106) , K= 3.6( 3.5-5)
* Liver function: total protein serum 6.3 (6.2-8.2)
Albumin 2.7 (3.7-5.3), globulin 3.6 (1.6- 3.6), bilirubin 0.2 (0.2-1.5)
Diagnosis
Pneumonia.
Treatment
40
He was given syrup ventolin 3.5 ml, rocephin 1 gm IV, syrup klacid , syrup
mucopront, suppositories voltaren, calpol syrup.
Rocephin. Dose 20-25 mg / kg or single doses 2 gm it has log duration of action.
Klacid. Dose 62.5 mg /kg if body weigh (8-12kg)
Voltaren . Dose 1-3 mg/kg daily in divided dose (12.5 mg and 25 mg suppositories)
Calpol syrup. Used to treat fever and pain. Not taken with paracetamol it will increase
hepatotoxocity.
Comment
-
-
-
In this case pneumonia may be caused by any interference with the defense of
the respiratory tract or the normal drainage of the lung, e.g. common cold. Usually
within a week of the onset of the cold, the patient becomes rapidly more ill, and
increase in temperature and high respiratory rate and cough.
Pneumonia remains an important cause of death.
X-ray changes may be minimal at the onset of illness conversely,
consolidation may remain on the x- ray for several weeks after the patient is
clinically cured.
The treatment of pneumonia will depend on the form of pneumonia.in this
case it has been treated by macrolide ( clarithromycin)
CASE: (10 ) A CHILD WITH SORE THROAT
41
Patient details
Name: Y.K, sex: male, age: 3 years old, weight: 15 kg, high: 100cm.
Case history
Y.K is 3 years old, 2 days ago his ear was hurting. He had a headache and fever, and
wasn't very active. He was breathing so loud that it sounded like he was snoring, and
complained that his neck hurt.
Sings and symptoms
Headache, fever, loud breathing, pain in throat
Laboratory tests
* He was a febrile with stable vital signs. Respiratory rate was 24 per minute.
* Examination revealed his nose to have greenish discharge. Tonsils were enlarged
without exudates with left greater than right and deviation of the uvula to the right.
His airway was patent.
* His neck revealed a painful left anterior cervical and subauricular area with fullness.
* He had shotty bilateral anterior cervical adenopathy.
* Lungs were clear and the rest of his physical examination was normal.
* CBC showed hemoglobin of 10.4 g/dl, hematocrit 28%, platelets 329K/mm3. A
WBC of 24.1 K/mm3 was high. His peripheral smear showed a normal differential,
with a left shift of 75% PMNs and marked toxic granulations. His electrolytes were
normal. Blood culture showed no growth. Iron studies were consistent with an iron
deficiency anemia.
* Lateral radiograph of Y.K neck revealed the retropharyngeal space to be
dramatically enlarged from the level of the nasopharynx to just above the thoracic
inlet. The computed tomography scan of his neck showed prominent retropharyngeal
soft tissues and left tonsil causing mass effect on the airway.
Diagnosis
Sore throat (tonsillitis)
Treatment
He was taken to the Pediatric Intensive Care Unit (PICU) for continuous observation
of his respiratory status and was given IV antibiotics. He never required intubation or
surgical intervention and had resolution of his symptoms by day 2 so that he could be
transferred to the floor. Daily bedside laryngoscopies were performed to document the
42
resolving abscess. He also had a repeat computed tomography scan on day 4, which
showed almost complete resolution. He will be sent home on oral antibiotics and iron.
Doctors prescribe for him Calpol 10 ml, Kiddi pharmaton, Augmantin, Amoxidine,
Brufen, Zinnat and Benylin.
Comment
History should include onset of the symptoms, severity, and associated symptoms
such as fever, rash, headache, nausea/emesis, and abdominal pain. Fever is often
associated with sore throat, as well as behavioral changes or decreased activity. An
exposure history including contact with ill persons, especially to group A betahemolytic streptococcus, is important.
Most children usually have a self-limited, localized infectious disease process. Viral
pharyngitis and URIs should be treated symptomatically with fluids, humidity and
anti-pyretics for comfort. Group A beta-hemolytic streptococcus can be confirmed by
a positive rapid antigen test and treated with antibiotics if positive. Alternatively, a
throat culture may be used and should always be done if a rapid antigen test is
negative. Group A beta-hemolytic streptococcus is sensitive to penicillin, which is the
drug of choice. Invasive disease should be treated promptly with attention to airway
control. Drainage of abscesses and early initiation of appropriate antibiotic coverage
is important.
Section III conclusion
43
There is no doubt that breastfeeding is best for both mothers and baby. To encourage
more mothers to breast-feed their infants, we must be prepared to support mothers
with education and practical information. These require those health care
professionals and understand the process of lactation, as well as the cultural
differences that affect a woman’s decision to breast-feed. The mother’s nutritional
requirements must be adapted to the foods easily available and culturally acceptable
to her. Free and low cost promotional materials need to be identified and used.
Hospital and clinic staff also needs to be thought to promote breastfeeding and
support families who make this choice.
* Mothers who breast-feed have a special and unique relationship with their baby,
and may say how much pleasure being able to nourish food and comfort their
offspring brings. Breast milk is the natural food for babies. Breast-feeding is also
convenient and cheap and protects a baby against some illness. It isn’t without
problems, but virtually all of these can be prevented or over come. The problem most
often experienced with breast-feeding is insufficient milk, which is a shame because
it is preventable problem.
* Breast feeding works as demand and supply babies the more time the baby spends
at the breast, the more milk is made.
General Health Care:
Looking after a child is perhaps the most important in the world. In most instances
our own experience, intuition, imagination and sensitivity equip as perfectly well to
carry out this care and it helps if we have confidence to listen and learn from
ourselves and our children. But we also need the wisdom to learn from others and to
know how and when to ask for help in the form of encouragement, emotional support
, advice , or practical assistance is desirable or even downright necessary .
Caring For Growing Child :
44
Once your baby is born its important to take advantages of the routine tests and
development assessments after by your family, doctor, and health visitor or clinic
doctor. These away of screening thousands of normal, healthy children in order to
pick up problems in a few. The early detection of many problems can save both your
child and you from unnecessary suffering or worry in the future. One such test is the
guthrie test, used soon after birth to detect the rare genetic disorder, phenylketonuria
. It involves making a tiny pinprick on your baby’s heel and taking a few drops of
blood for testing.
References:
45
*Nutrition in pregnancy and lactation.
*The effects of drugs on the fetus and nursing infant.
*Pregnancy and children (nicky wesson).
*The complete guide to child health ((DR. penny stanway)).
*Basic and clinical endocinology ((fracis S. greenpan and peter H. forsham)).
*Text book of pharmacology ((wc bowman / MJ Rand )).
*Nutrition in mother and child health
*The essential guide to prescription drugs ((James J rybacki, Pharm. D. and James w.
long, M.D.))
*paediatric primary care , 3rd edithion catherine de anglies
46