VARICELLA VIRUS (CHICKENPOX) VACCINE

VARICELLA VIRUS (CHICKENPOX) VACCINE

A live attenuated varicella virus vaccine (Varilrix, Okavax) provides a high degree of protection against chickenpox. It is quite expensive.

Indication

Active immunization against chickenpox after 1 year of age.

Dose

Varilrix is administrated as a single dose(0.5 ml SC) 1-12 years of age. Thereafter, i.e. 13 years and later, it requires to be given in two doses 6-10 weeks apart.  The other varicella virus vaccine, Okavax, is recommended as a single dose for all ages.

Contraindications

1. Acute severe febrile illness
2. HIV subjects with lymphopenia (TLC <1200 mm^3)
3. Neomycin hypersensitivity

Adverse reactions

Both the vaccines are quite safe and well tolerated. Locally, a mild transient reaction may occur. Rarely, rash may be encountered.

Protection

In children exposed to chickenpox case, efficacy is 80% in protecting against chickenpox provided that it is administrated within 3 days of exposure to a case of chickenpox.

TYPHOID VACCINATION

  

TYPHOID VACCINATION

Currently recommended vaccines are:

1. Oral typhoid vaccine: Oral S.typhi (Typhoral), and
2. Injectable Vi capsular polysaccharide typhoid vaccine (Typhim Vi, Vac Typh, Typhivax, Typho Vi, Tyvax-Vi)
3. Classical: Whole-cell killed. TA vaccine as it also includes S.Paratyphi A.

Oral typhoid vaccine It contains Ty 21 live attenuated mutant strains of S, typhosa. The dose is one capsule on day 1,3 and 5 one hour before a meal, given every 3 years. The vaccine is well tolerated; rarely slight gastrointestinal upset and rash may occur. It confers a protection varying from 67 to 95%. Storage between 2 to 8 degree C and protection from light is vital for its stability.

Contraindications include immunodeficiency, immunosuppressant drugs, antimitotics, certain antibiotics and sulfas active against salmonella, acute febrile illness, GIT infection, and pregnancy.

Polysaccharide Vi typhoid vaccine It contains purified Vi capsular polysaccharide (ViCPS). The dose is one injection (0.5 ml containing 25 meg of ViCPS) given SC or IM as a single dose every 3 years. It confers a protection of 75 to 100%. Only mild local pain and fever may rarely occur as side-effects. Contraindications include hypersensitivity and pregnancy.

Ideally, for maximal protection, these vaccines are recommended to be administrated after 5 to 6 years of age. Nevertheless, in view of increasing occurrence of typhoid fever under 5 years of age, starting typhoid immunization at 18-24 months with injectable vaccine in endemic areas is justified.

Whole cell killed TA vaccine is quite cheap (though at present its production is suspended). It is given in two doses 0.25 – 0.5 ml each (SC) at an interval of 4-6 weeks, starting at 6 months of age or later. However, it is likely to cause side-effects such as local pain and induration, pyrexia and body pains over the next 2-3 days. Reactogenicity is less in Monovalent (Containing endotoxin of S.typhi only) vaccine, acetone killed and dried preparation (AKD vaccine). Revaccination every 3 years is needed.

The following improved new typhoid vaccines which can be given to the infants too are under clinical trial:

1. Genetically engineered strains of S.typhi as single dose live oral vaccines having higher immunogenicity over Ty 21 a.
2. Parenteral Vi-conjugate vaccine that stimulates higher titers of Vi antibodies than conjugated Vi polysaccharide and elicts immunologic memory.

Whole cell (conjugated) typhoid vaccine is safe and can be given to even infants.

THE CHILD WITH SHORT STATURE

THE CHILD WITH SHORT STATURE

Deflation

Short stature is defined as length/height

1. Below 3^rd percentile for age or
2. Below more than 2 standard deviation (SD) of mean forage

In addition, the height velocity is usually < 25^th percentile for age.

Etiology

Short stature is a common pediatric problem. Most enlightened parents are keen to know if their child, who had not been keeping pace with the healthy peers of his age, “ is leading for dwarfism.” Obviously, the doctor must evaluate the child fully, bearing in mind that a large number of etiologic factors cal lead to short stature.

Short stature may be primary or secondary. Primary short stature is usually due to an intrinsic defect in the skeletal system as a result of some genetic or prenatal damage (say, IUGR). Here, potential for normal bone growth is impaired through skeletal age is unaffected. Main affect is on diaphyseal growth.

Secondary short stature is characterized by impairment of bone age and height to the same extent. Here, the potential for reaching the adult height is subject to availability of proper treatment.

Diagnostic approach

Evaluation should be based on a good history and physical examination, routine investigation, bone age and study of growth rate. Hormonal studies and Karyotyping are needed in selected cases.

In anthropometry, height velocity is more useful than a single recording of the height. It is calculated from at least two accurate readings at a gap of 6 months (preferably one year). A velocity of less than 4 cm per year between 5 years of age and adolescence is considered pathologic. For younger children, it varies with age: 15 cm for 0 to 6 months, 7 cm for 6 to 12 months, 10 cm for 1 to 2 years, and 5 cm for 2 to 5 years.

Body proportion are considered to be most accurate index of height. Upper segment/lower segment ratio is increased in hypothyroidism and short-statured dwarfism(achondroplasia).

Measurement from midfinger tip to midfinger tip (span)is case of fully outstretched arms and hands is increased(more than height) in spondyleopiphyseal dysplasia (Morquio disease)

Measuring parent’s  height is of value. The so called midparental height, a genetic component, gives the subject’s target height. It is determined as mean of father and mother’s heights plus 13 in case of boys and minus 13 in case of girls.

If weight is less proportionally reduced than height, nutritional deprivation must be seriously considered. On the contrary, if weight is nearly normal but height is significantly less, hypothyroidism must be seriously considered. Growth hormone deficiency and hypercorticism is also figure in the differential diagnosis.

Children with delayed puberty and short stature should arouse suspicion of sex chromosomal anomalies such as Turner syndrome. Here stature, despite timely onset of puberty, is likely to end up with short stature. In “late maturers”, both short stature and delayed puberty coexist. These latematures ultimately attain better height compared to early maturers.

Bone age, assessed through radiologic examination of certain bones and then comparing the appearance and fusion of epiphyseal centers with standard normal radiographs for different ages, is of considerable value. In infancy, knee, wrist and hand and in later yars elbow, wrist and hand are appropriate sites.

With the availability of assessment mentioned so far, the following guidelines are suggested.

1. If height age falls within 2 years of the chronologic age, the subject need not be considered to have short stature.
2. If height is less than the chronologic age and the bone age equal to height age, slow growth – in other words constitutional delay- is the likely cause of short stature. In this situation, the child may well to attain his normal height subsequently.
3. If the height age is less than the chronologic age and the bone age equal to chronologic age, genetic short stature is the diagnosis. Such a child has short parents and is likely to remain short.
4. If bone age is less than chronologic age, one should consider constitutional growth retardation, hypothyroidism, malnutrition, growth hormone deficiency and chronic systemic disease as the cause of short stature. Besides radiology and routine investigations, including meticulous stool examination on at least 3 successive days, it should be ascertained if there is need for intensive workup. The indications for  such a workup include

-          Height over 2SD less than the mean for that age

-          Growth (height) velocity less than 4 cm per year.

-          Growth centile showing subnormality in relation to family stature (midparental height)

5. Inappropriate bone age compared to height age and actual (chronologic) age

-          Existence of characteristic features of an endocrinal cause or a syndromal

State

Specific investigations include:

1. Buccal smears
2. Thyroid function tests
3. Somatomedin-C measurement
4. Cortisol, LH, FSH, PRL, testosterone, estrogen levels
5. Urinary iodine levels
6. Complete Karyotyping
7. Malabsorption studies
8. Renal acidification test
9. Urinary aminoacidogram
10. Imaging studies like ultrasound, CT scan (pituitary, adrenals, pelvic organs).

Management

Even if no treatable cause is found , the situation should be explained to the parents. Only established indication for growth hormone therapy is growth hormone responsiveness in case of:

1. Biochemical GH deficiency supported by stimulation tests, after thyroid function has been shown to be normal, plus slow growth velocity, and
2. Slow growth velocity in idiopathic short stature.

Today’s genetically engineered GH i.e. recombinant human GH (rhGH) therapy costs US$ 4000 to 8000. It is mandatory to start such a therapy before 11 years of age for attaining the optimal height. Recombitant GH is administered in a daily dose of 0.1 unit/kg (SC), preferably at night, until adult height is attained. Usually height gain is 10-12 cm in first year and 6-8 cm every year subsequently. More recently, it has been advocated that GH therapy should preferably be monitored by insulin-like growth

Factor-1(IGF-1) to ensure safety and efficacy of GH. Excess GH and IGF-1 exposure and malignancy are known risks of GH therapy.

Obesity

Despite overwhelming problem of nutritional deficiencies in developing countries, obesity too is encountered, especially among the infants and children of the elite who ape the lifestyle of the west.  

SPINE AND BACK EXAMINATION OF KIDS

SPINE AND BACK EXAMINATION OF KIDS

Look for scoliosis, kyphosis, lordosis, dimples, sinuses, spina bifida, tufts of hair, stiffness of neck and back, any swelling, mongolian spots or tenderness. It is helpful to watch child’s gait. Remember that lumbar lordosis together with potbelly may well be a normal observation in the second year of life.

SKIN EXAMINATION OF INFANT OR CHILD

SKIN EXAMINATION OF INFANT OR CHILD

Note infant’s color for cyanosis, jaundice, pallor and caroteinemia.

Cyanosis

Definition: Bluish discoloration of skin and mucous membrane.

Peripheral: Present only in the periphery, i.e. limbs as a result of exposure to excessive cold, Raynaud’s phenomenon, arterial thrombosis, superior vena cava syndrome or traumatic compartment syndrome.

Central: Present in central regions as a result of pulmonary (cyanotle congenital heart disease), pulmonary (RDS, congenital diaphragmatic hernia, persistent fetal circulation, pneumonia, etc.), hematologic (polycythemia, hypercoagulability, methemoglobinemia, etc)or neurologic (encephalitis, encephalopathy, etc) disease.

Look for pigmentation. Localized bluish spots, usually on the buttocks and the back, are the so-called “monogolian spots”. They are self-limited, having no clinical significance. “Café-au-lait spots” may be associated with phakomatosis. Reticular pigmentation may be a feature of megaloblastic anemia or infantile tremor syndrome. In Addison disease, the pigmentation usually gives the skin dirty brown color and may also be present at the gum margins and cheeks.

Skin turgor is lost in dehydration and marasmus. In order to elicit pitting edema, greater pressure requires to be applied in children than in adults.

Presence of rashes, petechiae, ecchymosesor specific diseases should also be observed.

While examining skin, it is appropriate to look for subcutaneous nodules over bony prominences in suspected cases of rheumatic fever or rheumatoid arthritis.

Types of fever

Continuous fever: Present throughout the day with fluctuation < 1 degree C in 24 hours.

Examples: Pneumonia, UTI, infective endocarditis

Remittent Fever : Present throughout the day with fluctuation of > 1 degree C in 24 hours.

Intermittent fever: Present only during certain periods of the day. In between, temperature is normal. Examples: Malaria, kala-azar, juvenile rheumatoid arthritis.

Qutodian fever: Intermittent fever occurring daily

Tertian Fever: Intermittent fever occurring on alternate days

Quartan Fever: Intermittent fever occurring at 2 days interval

Fever with Rigors/Chills: It is encountered in infectious processes such as malaria, UTI, septicemia, etc.

RUBELLA VACCINATION

RUBELLA VACCINATION

Rubella vaccine is a live, attenuated vaccine. Rubella vaccination decidedly protects against the occurrence of so-called congenital rubella syndrome in the offspring.

Indication

1. Immunization of girls from 1 year to puberty
2. Susceptible women of child-bearing age(with hemagglutination test negative) provided they are not already pregnant and conception is unlikely in the subsequent 2 months.

Dose

0.5 ml(SC) upper arm as a single dose.

Contraindication

1. Febrile respiratory illness
2. Pregnancy

Adverse Reaction

Local pain, erythema and induration at injection site.

RECTAL EXAMINATION OF INFANT OR CHILD

RECTAL EXAMINATION OF INFANT OR CHILD

Note any anal fissure, polyp, prolapse or perianal erythema. Rectal examination should be done with a little finger that is gloved and lubricated with petroleum jelly. Once the finger is in, may assess the anal muscle tone. Note if the rectum is empty or full. The glove should be examined for faces, mucus and blood after the finger is withdrawn.

RABIES VACCINATION

RABIES VACCINATION

The old, conventional vaccine (Semple vaccine), an inactivated (by treatment with an agent called beta propriolactone) suspension of sheep brain, carries high risk of neuroplogic reactions (meningoencephalitis, ascending paralysis, polyneuritis). There is no justification for using it in the wake of availability of two potent and safe vaccines:

1. FLSC (Human diploid cells) vaccine is a sure, safe and painless preventive measure against hydrophobia. It is lympholized, stabilized suspension of rabies virus completely inactivated by B-proloctone. It is prepared on the human deployed cells. The vaccine is given as 1 ml subcutaneous injection immediately after exposure, on third day, 7^th day, 14^th day,30^th day and 90^th day. Incase antirabies treatment is begun immediately with cleansing of the bitten area with soap ad water administration of antirabies serum (human or animal) sixth injection may well be missed. HDC rabies vaccine, unlike the conventional antirabies vaccine, is very safe. In 1% redness and induration at the injection site may occur. Slight pyrexia and asthenia occur with the same frequency.
2. PCEC (purified chick embryo cell) is next to HDC in potency. Its administration is the same schedule as for HDC vaccine.

With the availability of HDC and PCEC vaccines, there is hardly any justification for using the old antirabic vaccine ( NTV).

Seroprophylaxis with rabies human immunoglobulin (RHIG), 20 IU/kg, or rabies animal immunoserum, 40Ill/kg, as a single injection is recommended in all cases with severe exposure. It should be given as soon as possible preferably immediately after the bite. After 7 to 8 days of bite, it is unlikely to be of any benefit. Half of the dose is infiltrated in the tissues around the bite and the remaining half is injected intramuscularly.

POLYVALENT PNEUMOCOCCAL VACCINE

POLYVALENT PNEUMOCOCCAL VACCINE

The polyvalent pneumococcal vaccine, (Pneumovax, Pnu-Immwri) claims to protect against most of the commonly encountered pneumococcal infections like pneumonia, bacteremia, meningitis and otitis media.

Indications

1. High-risk patients of chronic disease, e.g. cardiac, pulmonary, renal or metabolic disease
2. Patient whose spleens have been removed

Though children under 2 years are at high-risk of suffering from streptococcus pneumonia infection, the currently available vaccine is not effective in this age group because of poor immunologic response. It needs modification to be effective in them.

Dose

Dose is 0.5 ml(IM,SC). Revaccination after 3-5 years until age of 10 years.

Adverse reactions

These include local painful swelling, pyrexia, Guillain Barre syndrome, relapse of disease in ITP and anaphylaxis.

Special remarks

Against the routinely-used 21-valent unconjugated pneumococcal vaccine, recently a 7-valent conjugated vaccine has become available Western countries. It is relatively safer, more effective and can be employed even in infants as young as 2 months in 3 doses 2 months apart with a booster at 12-15 months. In United states, it has become an essential part of immunization schedule to prevent invasive pneumococcal disease, reduce antibiotic resistance among pneumococcal strains and reduce incidence pneumonia in children.

PHYSIOLOGY OF LACTATION

PHYSIOLOGY OF LACTATION

In relation to mother

Prolactin Milk-secreting Reflex sucking by baby at breast stimulates alveolar cells of the breast to secrete milk through secretion of the hormone, Prolactin, by the anterior pituitary. Prolactin level reaches the peak around 30 minutes of initiation of breast feeding, thereby getting ready milk for the next feed. Since pituitary gland secretes more prolactin during the night, breastfeeding at night specially helps to keep good supply of milk.

Oxytocin milk ejection reflex sucking by the baby sends sensory impulses from the nipple to the posterior pituitary gland. The hormone, Oxytocin, secreted by the gland reaches through blood to the breast, making the muscle cells around the alveolar cells contract. Thus, milk, which has collected in the alveoli, flows along the ducts to the lactiferous sinuses.

In relation to the infant

Rooting reflex guides the infant to reach the nipple and to have his mouth properly attached to the breast. A good attachment (termed “laching”) with nipple and enough of areola into infant’s mouth is essential for effective suckling. Suckling reflex helps the infant to draw out milk from mother’s breast. It consists of drawing the nipple and areola into the mouth, compressing it between jaw-togue and palate and then drawing out milk by peristaltic movement of the tongue. Swallowing reflex helps the baby to swallow milk when mouth is full of it(after one to three suckles). He takes the breath after swallowing.

It takes about a second or so for the “suckle-swallow-breathe” cycle.

PEDIATRIC WATER REQUIREMENTS

PEDIATRIC WATER REQUIREMENTS

It is second only to oxygen as a “must” for survival. Compared to adults, infants require much larger amount of water per unit of body weight. Its requirements at different ages are given below

Age range                                     Water requirement (ml/kg)

First 3 days                                    80 to 100

3 to 10 days                                   125 to 150

15 days to 3 months                       140 to 160

3 to 12 months                               150

1 to 3 years                                    125

4 to 6 years                                    100

7 to 9 years                                     75

10 to 12 years                                 50

PEDIATRIC NUTRITIONAL REQUIREMENTS

PEDIATRIC NUTRITIONAL REQUIREMENTS

Adequate nutrition is of paramount importance during childhood, especially in the first 3 years of life, when growth is most rapid and the child is,  by and large ,totally dependent on his caretakers, usually the parents. Since an important factor is responsible for adequate growth is balanced nutrition, erroneous nutrition leads to inadequate growth in addition to undernutrition and poor weight gain. Naturally, a basic knowledge of  nutritional requirements at various ages as also sources of such vital nutrients as vitamin A and micronutrients as iron and zinc is mandatory. The term, energy requirement, denotes the amount of dietary energy required to balance energy expended and deposited in new tissues (growth)

In order to meet the growth needs in first 3 years and during adolescence, a higher energy dense diet(less complex carbohydrates and larger quantity of fat) is indeed.

Water, protein, carbohydrates, fats, vitamins and minerals are the chief constituent of food. These six factors form the human body in the following way: water 63%, proteins 17%, fats 12%, carbohydrates 1%, vitamins and minerals 7%.

NOSE EXAMINATIONS OF INFANT OR CHILD

NOSE EXAMINATIONS OF INFANT OR CHILD

It should be examined for patency, discharge, bleeding, deviated septum, flaring of nostrils, foreign body, polyp and depressed bridge.

NEUROLOGIC EXAMINATION OF KIDS

NEUROLOGIC EXAMINATION OF KIDS 

CNS examination of an infant or a young child frequently poses difficulties. This is particularly true in case of sensory examination. Evaluation of cerebral function, cranial nerves and their integrity, cerebellar function, motor system meningeal signs and involuntary movements should be done as and when indicated. In the case of new born, it is important to assess the primitive reflexes. An estimate about the developmental and mental age should be made.

Clubbing

Definition: Loss of natural angle between the nail plate and nailbed with boggy fluctuation of the nailbed.

Grading

Grade 1: Increased boggy fluctuation of the nailbed.

Grade 2: Obliteration of the natural angle between the nailbed and the nail plate

Grade 3: Increase in curvature and thickness of the nail plate from above downward and from side to side. Altered prostaglandin metabolism and proloiferation of the connective   tissue.

Causes

Pulmonary bronchiectasis, empyema, lung abscess, progressive pulmonary tuberculosis,   cystic fibrosis, etc. Cardiovascular infective endocarditis, cyanotic CUD, etc.

Gastrointestinal Malabsorption states, ulcerative colitis, Crohn disease, multiple polyposis.

Hepatic Biliary cirrhosis, chronic active hepatitis

Miscellaneous Congenital, familial, thyrotoxicosis, Hodgkin lymphoma, syringomyelia.

Clinical Elicitation in Doubtful cases

1. Depth at the base of the nail or greater than the depth at the distal interphalangeal joint.
2. Disappearance of the normal “window” when two fingers are approximated.
3. When the nail is rocked on its bed with examiner’s index finger and thumb, it appears to be floating.

Special features of neurologic examination of infants and children

1. A considerable information can be obtained by carefully watching and interacting with the  child during history taking and while he is moving about or playing.
2. The sense of touch or pain should be tested during rest of the examination or during play, “Let’s play… close your eyes and say “yes” when you feel the touch,” should be the examiner approach. Avoiding testing for pain without first preparing the child for it.
3. Muscle tone is well tested by lifting the child by the shoulders. A child with generalized hypotonia simply slips out of the hands. Second useful test is that such a child’s elbows are able to cross midline of the chest easily (scarf sign)
4. The signs of meningeal irritation may be absent in certain situations, say infancy, gross malnutrition, toxemia and septicemia
5. It is usual for the tendon reflexes to be exaggerated (brisk) in young children
6. Primitive plantar reflex may normally persist well up to 1 year. It is prolonged persistence, say beyond 2 years, must be considered abnormal.
7. A positive Macewen sign (cracked pot sign) in fast 3 years of life may well be normal.
8. As a rule, optic disc on fundoscopy appears rather pale even in normal children. Ignoring this fact may lead to overdiagnosis of optic atrophy.

Pediatric testing of cranial nerves

1. First (Olfactory nerve) Ask the child to close eyes. Find out the odors (say peppermint, orange, lemon, coffee or tea) he is familiar with. Then test for them.
2. Second (optic nerve) Test vision and do fundoscopy to watch the optic disc.
3. Third (Oculomotor nerve) As the child to flow a bright object or light in all direction without rotating the head. Watch any limitation. Also watch for size of the pupil.
4. Fourth (Trochlear nerve) Watch for downward movement of the eye in particular which is impaired in its involvement. Even at rest, the eye tends to move upward.
5. Fifth (Trigeminal nerve) Test sensation over forehead, cheek and lower jaw. Also, test for corneal reflex and jaw jerk.
6. Sixth (Abducent nerve) Test for lateral movement of the eye. In its involvement, the child fails to move his laterally (temporally). At rest too, such an eye has atendency to move medially(nasally).
7. Seventh (Facial nerve) Test for asymmetry of the face when child is asked to smile or laugh, show teeth, close the eyes and attempt wrinkling the forehead. Whistling too fails in its paralysis. In case of upper motor neuron lesion (supranuclear paralysis), forehead involvement is not elicited.
8. Eighth (Vestibulocochlear nerve) For auditory component, test or deafness or ringing in years. For vestibular component, test for positional nystagmus.
9. Ninth (Glossopharyngeal nerve) Test for gag reflexon touching child’s posterior pharynx with a tongue depressor.
10. Tenth (Vagus nerve)  Examine throat for position of uvula. The normal midline uvula turns to the healthy side in case of unilateral involvement)
11. Eleventh (Spinal accessory nerve) Ask the child to shrug shoulders  which showing drooping in its involvement. Moreover, he fails to move head away from the affected side.
12. Twelfth (Hypoglossal nerve) Ask the child to show the  tongue which is deviated to the involved side. The speech of the child too becomes thick. 

NECK EXAMINATION OF INFANT OR CHILD

NECK EXAMINATION OF INFANT OR CHILD

Neck is examined for head-holding, swelling, torticollis, JVP, sinuses or fistulas. Any webbing, bull neck or position of trachea should be noted.

MUMPS VACCINATION

MUMPS VACCINATION

Again, like measles vaccine, it is a live, attenuated virus obtained from the Jeryl-Linn strain (named after the child from whom it was isolated). Its protective value is of the order of 95% and it probably gives long immunity. It is supplied as lympholized powder which on reconstitution should be used promptly. The dose is 317 TCID (tissue culture infective dose) which should be administrated subcutaneously or by get gun. Mumps vaccine is very safe.

MOUTH AND THROAT EXAMINATION OF INFANT OR CHILD

MOUTH AND THROAT EXAMINATION OF INFANT OR CHILD

Note any unusual shape , cleft lip, nevi, lesions at the corners, ulcers on buccal mucosa, tongue or pharynx, spongy gums, dental caries or malocclusion, opening of the Stensen duct at the level of second upper molar, Koplik spots, hard and soft palate, tonsils and postnasal discharge.

If a baby can move his tongue over the alveolar margin (which is invariably the case), the so-called “tongue-tie” is out. Fissuring of the tongue occurs in many cases of Down syndrome. Tremors may suggest Werdnig-Hoffman disease. Frenular ulcer is a feature of pertussis. Macroglossia may be encountered in cretinism, and gargoylism. Glossoptosis occurs in association with micrognathia and cleft palate in Pierre-Robin syndrome.

MMR VACCINE

MMR VACCINE

Indication

MMR, a live attenuated vaccine(priorix), is recommended as a backup dose for protection against measles in the second year of life (at around 15 months of age, at least 3 months following primary measles vaccination in the first year).

Dose

0.5 ml(SC) at 15-18 months.

Contraindications

1. Immunodeficiency
2. Recent administration of immunoglobulins
3. Known anapjylaxis due to egg allergy

Adverse reactions

1. Fever and febrile seizures
2. Lymphadenitis
3. Parotitis

The suspicion of a causal relationship of MMR vaccine with autism is unfounded.

METHOD OF FEEDING/ PROVIDING NUTRITION

METHOD OF FEEDING/ PROVIDING NUTRITION

Broad guidelines for fluids and nutrition of LBW infants are discussed above.

Many LBW infants, especially those weighing > 1800 g, are strong enough to suckle well from the breast. This should be encouraged. However, care should be exercised to safeguard against distention of abdomen. This is best achieved though small feeds at frequent intervals. Breastfeeding should be considered as the preferred choice enteral feeding for all LBW babies. When it is not workable for some reason, gavage feeding(tube feeding) should be the choice, employing mother’s own expressed milk. There is sufficient evidence that necrotizing enterocolitis is far less in LBW infants fed mother’s milk than those on artificial feed. Further , LBW infants on own mother’s milk are known to grow faster than those on another woman’s milk.

Alternative method of milk feeding

Gavage (Tube) feeding

It is needed in:

1. LBW infants weighing < 1200 g or  <  30 weeks gestation after initial stabilization with IV fluids.
2. LBW infants weighing 1200-1800 g or <34 weeks gestation

Other indications of tube feeding are:

1. Baby getting tired quickly
2. Baby taking > 20 min to finish the feed.

For LBW infants, recommended size of the tube is No. 6 FG(French gauge) and No 4 FG in case of complicating respiratory difficulty. On an average about 16-17 cm of tube is needed to reach the stomach fro the gum margin. In a given situation, the tube is No. 6 FG (French gauge) and No 4 FG in case of complicating respiratory difficulty. On an average about 16-17 cm of tube is needed to reach the stomach from the um margin. In a given situation, the tube may be measured from the tip of the nose to the ear lobe and further to the ansiform cartilage. The measurement should be marked of the tube per se. In case tube feeding is required for a short period, it may be passed through the mouth. For this purpose, the wet tube is placed along the side of the tongue and then into the pharynx. The head-end of the baby needs to be raised.

If tube feeding is needed for several days, it should be passed through the nasal route into the esophagus and stomach. It should be kept in place. On the tube has been passed-irrespective of the route – its position should be conformed. To do this, gentle aspiration is required. The gastric fluid is usually colorless and acidic in reaction. If aspiration is difficult, some air may be injected and its entry into the stomach verified by auscultating the epigastric region.

Intermittent feeding: The outer end of the tube is attached to a syringe (20 ml) containing milk. It is important to bear in mind that milk should not be pushed, if safety is needed. Instead it should be allowed to trickle by gravity. The time taken by each feed nearly varies from 10 to 20 minutes, depending upon the size of the feed. This is about the time taken by an ordinary feed as well.

At the end of the feed, a few ml of plain water should be pushed to rinse the tube. If the tube is to be removed, it should be pinched so that no fluid trickles into the trachea as the end reaches past the larynx.

Continuous feeding (Intragastic Drip): Continuous milk drip has now won pride of the place in the feeding of LEW babies. Its advantages are many. E.g.:

1. Allow high milk intake
2. Weight gain is more
3. Less risk of regurgitation
4. Less risk of aspiration into the lungs.
5. Less risk of hypoglycemia
6. Nursing time is cut
7. Minimal handling of the infant

The technique of introduction of the tube into the stomach is same as in case of intermittent feeding. The outer end of tube is, however attached to the intravenous set containing milk. As intermittent feeding, infants head should remain slightly raised. His position should be supine. The tube should be changed every third day. It should be aspirated thrice daily. The bottle requires to be changed every 12 hours and the giving set every 24 hours.

Spoon feeding

The fact that even LEW neonates of 30-32 weeks gestation are good at swallowing even though their sucking may not be up to the mark forms the guiding principle of feeding by spoon. The tapering snout is placed at the angle of mouth. Then the milk is allowed to trickle slowly. The infant manages to swallow it without sucking. Repeat until the required quantity has been fed. It is good to be slow and patient, to avoid spilling of the feed. And also spoon is filled with milk and placed over the lips at the corner of mouth. Milk starts flowing into the mouth while the infant actively swallow it. Repeat the process until the calculated quantity has been fed. Avoid spillage. It is possible to find the quantity that has been spilled by wighing the napkin around baby’s neck before and after the feeding.

MENINGOCOCCAL VACCINE

MENINGOCOCCAL VACCINE

Meningococcal vaccine A+C, which contain 50 meg each of purified lympholized polysaccharide of Neisseria meningitides group A and C. Effectiveness of the vaccine is purely group specific.

Indications

1. All residents of an epidemic area
2. Close population groups, say schools
3. All contacts of an index case, especially family members(in addition to the drug prophylaxis).
4. High-risk groups: Asplenemia and immune (complement) deficiency.

Dose

Under 2 years: 0.5 ml (deep SC), preferably in deep infraspinal fossa, in a single dose. 2-4 years: 2 injections at 1 year gap Over 4 years: 2 injections at 5-year gap.

Side-effects

Local redness and edema, pyrexia

MEASLES VACCINATION

MEASLES VACCINATION

A live, attenuated measles vaccine(Schwartz strain from chick embryo tissue culture, Edmonston strain from human diploid cells), has a definite protective value of as high a magnitude as 95 to 100%. A single dose produce antibodies for an indefinitely prolonged period. Boosters are usually not needed. An aerosol measles vaccine has yielded gratifying results in Mexico. Besides convenience in administration, it may well overcome other limitations of the injection.

Age to vaccinate

The national recommendation for measles vaccine is at 9 to 12 months of age with revaccination at 15-18 months in the form of MMR vaccine. In high-risk situations it may be given earlier but, in that event, it must be repeated after a gap of 6 months.

Dosage

0.5 – 1.0 ml (SC,ID,IM)

Contraindications

1. Acute illness
2. Immunosuppressive therapy(steroids, antimetabolites, alkylating agents) over prolonged period
3. History of convulsions in the child or the family
4. Leukemia
5. Active tuberculosis
6. Immune deficiency states(hypogammaglobulinemia, severe HIV)
7. Recent gammaglobulin administration
8. Allergy/eczema

Adverse reactions/ complications

Practically no remarkable complications occur if the vaccine is administrated carefully and precautions taken in the wake of the aforesaid  relative contraindications.

1. Mild measle-like illness with fever and rash 5-10 days after immunization
2. Febrile reactions for a day or two from fifth to twelfth post-vaccination day in a proportion of the cases.
3. Even convulsions may occur.
4. Slight gastrointestinal upset and
5. Rhinopharyngitis
6. Toxic shock syndrome

Precaution

Reconstituted vaccine must be employed the same day and the leftover discarded.

LYMPH NODES EXAMINATION OF INFANT OR CHILD

LYMPH NODES EXAMINATION OF INFANT OR CHILD

Note the location, size, consistency, mobility, tenderness and warmth of lymph nodes, particularly in the suboccipital, preauricular, anterior and posterior cervical, submaxillary, sublingual, axillary, epitrochlear and inguinal regions. Posterior auricular and suboccipital adenitis may be the result of otitis externa, scalp infection or lice. Palpable nodes up to 1 cm in inguinal region and up to 3 mm in rest of the areas may well be passed as within normal limits in healthy children.

LINE OF TREATMENT IN SHORT STATURE OF KIDS

LINE OF TREATMENT IN SHORT STATURE OF KIDS

General: Good balanced diet, wormicidals, hematinics, zinc

Growth hormone deficiency: Replacement therapy

Hypothyroidism: Replacement therapy

Turner syndrome: Low dose estrogens, anabolic steroids

Systemic diseases: Specific therapy.

Idiopathic (ISS): Zinc supplementation

Skeletal dysplasia: Limb lengthening surgery possible through expensive and risky.

Familial and IUGR: No treatment

LIMBS AND FEET EXAMINATION OF KIDS

LIMBS AND FEET EXAMINATION OF KIDS

These should be examined for any deformity, asymmetry, hemihypertrophy, bow legs, knock knees, edema, any swelling or limitation of movements of the joints, etc. Do count the digits and the number of fingers and toes. Also look for incurving of the little finger, syndactyly, simian crease, platenychia or koilonychia, clubbing, and presence, absence or diminution of arterial pulses. It is absolutely within normal limits for many infants to have flat feet and bow legs.

                                                              

LACTATION FAILURE

LACTATION FAILURE 

Definition

Lactation failure is failure in the part of the breasts to produce adequate quantity of milk which manifests as failure to sustain growth in a normal infant within2 standard deviations of the standard for the infant in the first 6 months of age. Complete LF means total absence of milk flow or secretion of only a few drops of milk following regular suckling for a period of at least 7 day. Partial LF means insufficient milk flow by the mother who is otherwise regularly breastfeeding her baby so that the infant needs supplementation by artificial feeding for sustaining growth.

Etiology

LF is usually not the cause, but a consequence of a number of factors which are responsible for introduction of top milk under the following notion of “not enough milk”, or because of maternal-child separation, working mothers, sore/ cracked nipples, etc.

Etiology of lactation failure

Maternal factors: Psychosocial lack of motivation/confidence/will, dislike of BF because of wrong notions, stress and anxiety, rejection of baby, previous unpleasant experience, undue concern for figure, aping the west, influence of advertisements favoring breast milk substitutes.

Physical: Breast conditions, e.g. nipples that are retracted, cracked or sore, painful conditions, e.g. mastitis, engorgement or abscess, malnutrition, sickness, pregnancy, contraceptive pill, alcoholism, smoking, working mother.

Infant factors

Sick infant, prematurity, suckling problem, e.g. cleft palate, nasal block, oral thrush

Feeding factors: Prelacteal feeds, delayed initiation, poor technique, introduction of bottle

Prevention

The most important preventive measures are through antenatal check-up of the breasts, antenatal preparation of the mother for breastfeeding, feeding as early as possible after delivery, remedial measures or anatomical defects in the breast and complete emptying of the breasts. If necessary, even manual expression of milk following feeds may by done. Most of lactation failure can be prevented if the pediatrician forms a part of the team for the antenatal care, and the breasts of every expectant mother are carefully examined.

Treatment

Metoclopramide and chloropromazine may help certain mother with lactation failure to revert to normal milk production through their galactagogue effect. Nevertheless, remember, the best galactagogue is indeed the frequent suckling.

Relactation in partial lactation failure

Satisfactory relactation in these mothers is attained by motivation and encouragement. They need to be educated in the supremacy of breast milk and actively involved in achieving success with “commitment for the cause”. As the days ass by, the amount of top feed needs to be reduced in increments until the infant is entirely of mother’s milk.

Relactation in complete lactation failure

This is rather more difficult situation. In addition to motivation, encouragement and moral support, the following actions are warranted

1. Nipple stimulation exercises by nipple stroking, massaging the breast and rolling the nipple between thumb and the index finger.
2. Frequent suckling , at least 8 to 10 times a day, each session lasting 10 to 15 minute for each breast.
3. Drop and drip method may be employed if the infant fails to suckle for 8 to 10 minutes.
4. Method consists in expressing some breast milk or topmilk in a cup and gradually pouring it over as drops over the breast. As the drops slide over the nipple down into infant’s mouth, he is stimulated to suckle at the breast.
5. Nursing supplement may be used to induce suckling in the infant. This gadet consists of a fine infant feeding tube. The tube is employed as a drawing straw. It is made to pass from milk in a cup to the infant’s mouth. Its end is placed along with mother’s nipple so that the baby suckles at both the nipple and the tube is simultaneously. As he suckles when milk passes in to his mouth, the nipple gets stimulated, thereby enhancing the prolactin reflex which increases the milk production.

Evidence of successful relactation

1. Appearance of first milk secretion in 2 to 10 days.
2. Partial restoration of breastfeeding with reduction of top feed to half of the initial
3. Complete restoration of breastfeeding with total withdrawal of top feed
4. Satisfactory weight gain by the infant.

JAPANESE ENCEPHALITIS (JE) VACCINE

JAPANESE ENCEPHALITIS (JE) VACCINE 

Indication

Single most important control measure against Japanese encephalitis.

Dose

Formaline inactivated mouse drain or hamster kidney vaccine: Two doses, 1 ml each (0.5 ml for under 3 years age) are administered at an interval of 7 to 14 days subcutaneously. After 6-12 months, a third dose is given. Every 3 to 4 years, a booster dose is needed. Live-attenuated vaccine: 2 doses, 4 weeks apart(SC)

Contraindication

JE vaccine is contraindicated in high fever, diabetes mellitus, liver and heart disease and immunodeficiency

Adverse reactions

JE vaccine is quite safe

INFLUENZA VACCINE

INFLUENZA VACCINE

Influenza (flu) vaccines Vaxigrip (Sanofi-Pasteur) and Fluarix (GSK) are available.

1. This vaccine (A and B) prepared from currently prevalent strains is an inactivated vaccine, giving a reasonable degree of protection for a short time only
2. Chronic aspirin therapy
3. HIV infection
4. Pediatric subjects, doctors and nurses, etc. who become grossly overworked during influenza epidemics.

Dose

6 months- 6 years: Two doses of 0.25 ml (SC,IM) at 4-6 week interval

6-9 years : 0.5 ml(SC,IM) at 4-6 week interval

>9 years: 0.5 ml (SC,IM) as a single dose

Revaccination is needed every year

Protection

Only 6-12 months.

Adverse Reaction

1. Local pain, induration and erythema
2. Anaphylaxis
3. Allergic reactions to components of vaccine

Contraindications

Hypersensitivity to its components.

Storage

2-8 degree C. 

INFANT PARENTAL NUTRITION

INFANT PARENTAL NUTRITION

It may become mandatory to resort to parental nutrition in the following life-threatening situations in which enteral feeding has failed to establish or central feeding is not possible for prolonged periods:

1. ELBW babies (<1000g).
2. LBW babies unlikely to attain full enteral nutrition by day 5 for some associated problem such as intractable diarrhea, necrotizing enterocolitis, surgically correctable GI anomaly (omphalocele, gastroschisis, tracheoesophageal fistula, malrotation with volvus, diaphragmatic hernia, etc.), extensive bowel resection.

This regimen provides adequate fluids and electrolytes, energy (from glucose, protein and lipids), amino acids and vitamins and micronutrients for sustained growth of the LBW babies. With this method, providing  around 100kcal/kg/24 hours, a weight gain of 15 g/kg/24 hours is likely to be attained in the first week.

Parenteral nutrition may be carried out employing an indwelling central venous catheter (per cutaneous or surgically-placed) or through a peripheral vein.

Complication of Parenteral nutrition and remedial measures

Complication                                            Action Recommended

Catheter-related Complications                  Aseptic preparation of the infusate                

Sepsis/septicemia(usually from                    Appropriate antibiotics Removal

Coagulasenegative staphylococcus)            of line if sepsis persists

Thrombosis

Extravasation of fluid

Accidental dislodgement of catheter

Metabolic Complications                            Biochemical and physiologic monitoring

Hyperglycemia

Azotemia

Nephrocalcinosis

Hyperlipidemia

Hypoxemia

Hyperammonemia

Cholestatic jaundice

Liver disease

Metabolic bone disease

INFANT NONNUTRITIVE SUCKLING

INFANT NONNUTRITIVE SUCKLING

When the LBW infant is being kept on IV fluid or tube feeding, he may be given experience of suckling by providing opportunity to suckle the empty breast. This experience stands him in good stead later at the time of transition to nutritive suckling.

This is a method of exposing a neonate, who is being kept on gavage feeding or intravenous fluids/nutrition for such reasons as prematurity, low birthweight or such illness as birth asphyxia, septicemia, etc to experience of suckling on emptied breast that is expected to stand him in good stead later at the time of transition to nutritive suckling.

Characteristics

Nonnutritive suckling consists of a rhythmic alternation of bursts of rest periods with a mean intersuckling interval of 0.3 to 0.5 second. Nutritive suckling, on the other hand, consists of almost continuous streams of suckles with a mean intersuckling interval of 0.1 second.

Advantages

Nonnutritive suckling influences the neonatal behavior of a preterm baby in the following ways:

1. Restless state is less frequent
2. Behavior distress during a painful procedure is altered
3. Oxygenation, weight gain and gut transit time are increased
4. Nutrient absorption is improved. Intermittent changes in pressure during suckling are necessary to stimulate secretion of the lingual lipase, facilitating fat absorption
5. Transition from gavage to breast becomes easier.
6. Nipple stimulation by repeated suckling results in enhanced milk supply.

An added advantage of nonnutritive suckling is that it provides significant emotional support and satisfaction to the mother who is upset by the high risk status of the infant.

Procedure

Make sure that the procedure is carried out in a reasonably warm room to safeguard against chilling of the infant. Then, mother is asked to express out milk from each breast as much as possible. After this, the baby is allowed to suckle on each breast. The requisite amount of the expressed milk is administrated by tube feeding. Gradually, the infant should be suckling on the emptied breast before each and every gavage feed.

As soon as the infant develops well sustained suckling, start direct breastfeeding. Slowly withdraw all gavage feed and let the infant be entirely on direct breastfeeding.

INFANT INTRAVENOUS (CENTRAL) FEEDING

INFANT INTRAVENOUS (CENTRAL) FEEDING

First 2 Days

For LBW of SGA (SFD) type, 90-100 ml/kg of 5-10% glucose is recommended. For LEW of short gestation type, 60-70 ml/kg of 5-10% glucose suffices

Later

Since the LBW needs extra-sodium and potassium, N/ 5 saline with 15% potassium chloride (1 ml added to 100 ml infusate) should replace the 5-10% glucose after 2 days. The readymade Isolyte-P serves well as an alternative.

HEPATITIS B VACCINE

HEPATITIS B VACCINE

Hepatitis B vaccine consists of hepatitis surface antigen related protein- a highly purified suspension of inactivated, alum-adsorbed HBsAG particles. Now only DNA recombitant, i.e. genetically engineered (Engerix-B, Shanvac-B,HB Vac, Enivac HB, Revac-B) vaccine is in vogue worldwide. The world health Organization (WHO) recommends incorporation of the hepatitis B vaccine as the seventh vaccine in the routine immunization schedule in the south-East Asia and the Pacific.

Indications

IAP now recommends it as a routine vaccine. High risk situation in which it must be given include

1. recipients of multiple blood transfusions
2. household sexual contacts of carriers of HBV
3. users of Parenteral drugs such as heroin
4. hemosexually active males
5. hemodialysis subjects
6. immigrants from areas of high HBV endemicity
7. babies born to mothers with HBsAG positive blood

Dose

The vaccine is administered intramuscularly in a dose of 0.5 ml(10 mcg) and 1ml(20mcg) for children below and above 10 years, respectively. IAP recommends it at birth, 6 weeks and 14 weeks or 6,10 and 14 weeks. Else, it may be given in two doses 1 month apart followed by a booster 6 months later.

Postexposure prophylaxis According to IAP recommendation, if the pregnant woman is known carrier of HB virus, her neonate should be given HB immune globulin (HBlg) within 12 hours of birth and also one dose of HB vaccine with a separate syringe and needle over a different site on the body. If HBlg is not available, HB vaccine must be given. If there has been a delay of over 12 hours, HBlg need not be given, However, HB vaccine has got to be started. The second dose of the vaccine is given 4 weeks later and the third 5 weeks (4-6 weeks) later. It may well be convenient to give the third dose at the same time as measles vaccine, at or after 9 months.

In case the mother is known not to be a carrier of HB, there is no need to give HB vaccine immediately after birth. It can conveniently be given at the first visit  for other vaccines, such as 6 weeks when a dose of DTP is due. The second dose of HB vaccine may be given 4 weeks later and the third at the time of measles vaccine.

Contraindications

Hypersensitivity to its components.

Adverse Reactions

1. Transient soreness, erythema and induration at injection site.
2. Low grade fever

There is no evidence that it causes development or flare-up of demyelinating diseases such as multiple sclerosis (suspected in France a few years ago).

Storage

2-8 degree C