Picture Diagnosis in Pediatrics Rabigh Medical College

Picture Diagnosis in Pediatrics

Dr Mohamed Hesham Prof of Pediatrics Rabigh Medical College ??? ??? ??? ??????????????

Newborn baby - Just seconds old

Newborn Baby - Just seconds old

Newborn, skin color

• Babies' skin is often quite blue or grey looking when they are first born. • Sometimes this means they may need some extra oxygen, but often they go pink quite quickly all on their own. Newborn resuscitation, suctioning Vernix caseosa Vernix caseosa

• The skin at birth is covered with vernix caseosa. This whitish greasy coat is produced by epithelial cell breakdown and, in utero, protects the skin from the amniotic fluid. Normal newborn baby Normal newborn baby

• This baby was born just a few moments before the photograph. Does he look healthy? Yes, pink and good tone and position of limbs. What should be done next? • Check that he is breathing well, that the umbilical cord is securely clamped or tied, then dry him with a clean towel and keep him warm, preferably in his mother’s arms or on her breast.

Giving vitamin K

• A vitamin K injection (1 mg) is being given to a newborn. This is to prevent hemorrhagic disease of the newborn. • Note the moulding of the baby’s head due to pressure during labour. This recovers over hours or a few days.

Fetal position

• Babies have been in the flexion foetal position for a long time and they will often feel most comfortable in this position for some time. • Positional talipes is expected and will resolve by time. Newborn baby, peripheral cyanosis Neonatal resuscitation Bag and mask ventilation Neonatal resuscitation Bag and mask ventilation, preterm baby Neonatal Resuscitation – ET intubation Lanugo hair Lanugo hair Lanugo hair

• During human development, the lanugo grows on fetuses as a normal part of gestation, but is usually shed at about 33 to 36 weeks of gestational age. • The presence of lanugo in newborns is a sign of premature birth. Mongolian spots Mongolian spots Mongolian spots Mongolian spots Mongolian spots Mongolian spot

• Bluish discoloration of an area of skin in lumbosacral region. • It is of no significance, may be mistaken for bruising. • Fades gradually as the infant grows older.

Salmon patches, nevus simplex Salmon patches, stork bite Stork bites and angel kisses Salmon patches, stork bite

• Transient macular stains (salmon patches, stork bite, angel’s kiss) are present in 70% of normal newborns. • They are small, red, irregular patches resulting from dilated dermal capillaries. • Usually found on the nape of neck, eye lids and glabella. • Most of them fade by 1 year of age. Caput Succadaneum Caput Succadaneum Caput Succadaneum

• Caput succedaneum is swelling (soft tissue edema) of the scalp in a newborn. It is most often brought on by pressure from the uterus or vaginal wall during a vertex delivery. • Swelling can extend over the midline of the scalp. • No treatment is necessary, and it usually subsides spontaneously within a few days. Scalp layers Cephalhematoma Cephalhematoma Cephalhematoma, bilateral Cephalhematoma

• It is a subperiosteal hemorrhage. • Treatment is conservative, and aspiration is contraindicated.

Neonatal teeth Neonatal teeth Neonatal teeth

• Natal teeth are teeth that are present at birth. Neonatal teeth are teeth that emerge through the gingiva during the first month of life. • It is recommended to leave them alone, unless they are causing difficulty to the infant and mother. • However some recommend that they be removed as the tooth can cut or amputate the tip of the tongue. Moro reflex Moro reflex Moro reflex Moro reflex

• The most common primitive reflex that is normally elicited in newborn, and disappears by 4-6 months. • It can be elicited by startling the baby. • Absent reflex may be due to intracranial injury, cerebral depression, or prematurity.

Neonatal reflexes Stepping reflex Stepping reflex When the soles of infant’s feet touch a flat surface they will attempt to 'walk' by placing one foot in front of the other. Tonic neck reflex

Precipitation of uric acid (urate) crystals in the diaper- Pink diaper

Pink diaper

• Newborns and young infants may have wet diapers that appear either orange or pink- tinged. • This can be a frightening thing for new parents, because it looks very much as though the child has blood in his or her urine. • No treatment is needed. Preterm Baby Born at 25-26 Weeks Preterm Baby Born at 27-28 Weeks Preterm Baby Born at 31-32 Weeks Preterm Baby Born at 35-36 Weeks

Testing for dislocation of the hips in a newborn

• Every newborn baby should be tested for congenital dislocation of the hips. If diagnosed and treated early, the results will be good. • The pelvis is stabilized with one hand. With the other hand, the examiner's middle finger is placed over the greater trochanter and the thumb around the distal medial femur. The hip is held flexed and adducted. The femoral head is gently pushed downwards. If the hip is dislocatable, the femoral head will be pushed posteriorly out of the acetabulum.

Neonatal jaundice

Neonatal jaundice Neonatal jaundice

• Jaundice in a newborn is common and may be simple, or it may be serious and life- threatening.

Jaundice, newborn Phototherapy Phototherapy

Phototherapy

• Exposure of infants to blue, white, or green lights of wave length 450-460 nm decreases un-conjugated bilirubin levels. • It is mainly indicated for levels above 15 mg/dl in full term infants. • Side effects include hyperthermia, dehydration, loose stools, and skin rash.

Erb’s palsy Erb’s palsy Erb's Palsy (Brachial Plexus Palsy) Erb's palsy

• It results from injury of 5 and 6 cervical nerves. • Moro reflex is absent on the affected side, but grasp reflex is intact. • Treatment is by physiotherapy from second week. Facial palsy, left side Facial palsy Facial palsy

• Causes include compression of facial nerve by pressure from forceps blades but may occur after normal delivery. • It presents as unilateral weakness of facial muscles and drooping of mouth. • Most cases resolve within a few weeks after birth.

Umbilical granuloma Umbilical granuloma Umbilical granuloma

• It presents as a persistent serosangunious discharge and a fleshy protuberance from the base. • It can be treated by local application of silver nitrate or rarely by surgical excision.

Umbilical hernia Umbilical hernia Umbilical hernia

• In most cases umbilical hernias are harmless and will disappear before the child's third birthday. As the child grows and begins to move around the abdominal muscles strengthen and the protrusion is drawn in. • There are rarer instances in which the hernia needs surgical intervention.

Congenital hypothyroidism Note the broad nasal bridge, thick lips, and umbilical hernia Congenital hypothyroidism Dull facies, periorbital edema and large tongue Congenital hypothyroidism

• Clinical features includes coarse facies, large protruding tongue and umbilical hernia. • Routine screening of all newborns within a few days of birth ensures early diagnosis and early treatment, to prevent mental retardation.

Newborn screening

Umbilical infection Inflammation, redness and swelling, around the umbilical stump Umbilical infection Necrotizing enterocolitis Necrotizing enterocolitis

• This is a serious bowel infection in newborns. It is commoner in low birth weight infants and may present with signs of bowel obstruction. • These are severe abdominal distension with tenderness and bile stained vomiting. Look for blood stained stools Cleft lip Cleft lip and palate Cleft lip and palate, bilateral Cleft lip and palate

• Complications include feeding difficulties, speech problems and deafness. • Management of feeding by a large teat, spoon or tube feeding. • Surgical repair usually gives excellent results. Undescended testicles Bilateral undescended testicles Undescended testicle (cryptorchidism)

• Undescended testicle (cryptorchidism) is a testicle that hasn't moved into scrotum prior to the birth of a baby boy. Usually just one testicle is affected, but in some cases both testes may be undescended. • An undescended testicle is more common among baby boys born prematurely or before 37 weeks.

Undescended testicle (cryptorchidism)

• For most boys born with one or two undescended testicles, the problem corrects itself within the first few months of life. • If the infant has an undescended testicle that doesn't correct itself, surgery can be needed.

Imperforate anus Imperforate anus Imperforate anus

• This is usually diagnosed during routine examination immediately after birth. • Other anomalies are found in 60% of cases. • Most cases need colostomy performed in the neonatal period. Talipes equinovarus Talipes equinovarus Talipes equinovarus

• It can be differentiated from positional talipes because it can not be passively corrected. • Treatment is by splinting, but surgical release may be needed.

Hydrocephalus Hydrocephalus Hydrocephalus Hydrocephalus

• It is dilatation of the ventricular system. In infants, the head is enlarged with a large bulging anterior fontanelle, scalp veins are prominent, and the eyes are deviated downward (sun-set sign ). • Treatment is by shunt operation.

Meningomyelocele

Meningomyelocele Meningomyelocele Meningomyelocele

• It is a neural tube defect. • Antenatal diagnosis is possible by ultrasound examination. • Hydrocephalus occurs in most of the case. • Paralysis of both lower limbs is expected. • First aid includes covering by sterile dressing and neurosurgical referral.

Trisomy 21, Down syndrome Simian crease Simian crease

• It is a transverse palmar crease seen in many chromosomal aberrations, e,g, Trisomy 21. • It can be seen in normal persons, of course without other features of trisomy 21. Sandal Gap Deformity

Impetigo (superficial pyoderma)

Impetigo contagiosa

• Impetigo is a bacterial skin infection. It most commonly causes clusters of tiny blisters on the skin that ooze and form a golden crust. Touching the fluid can spread the infection to other parts of the body or other people. • It is often caused by staph bacteria but also can be caused by strep bacteria. This type of impetigo is most common in kids ages 2 to 6. If treated with antibiotics, the sores usually heal without leaving scars. Oral moniliasis (thrush) Oral moniliasis Oral moniliasis

• It is a fungal infection caused by candida albicans. • It appears as white adherent plaques on the buccal mucosa and tongue. • Treatment is by topical nystatin or miconazole.

Candidal Diaper Dermatitis

Candidal Diaper Dermatitis This bright red rash involves the intertriginous folds, with small "satellite lesions" along the edges. Candidal Diaper Dermatitis Candidal Diaper Dermatitis

• It gives a bright red confluent rash in the napkin area or around the anus. • Typically, there are discrete satellite lesions lying peripheral to the rash. • Treatment by topical nystatin cream.

Herpetic stomatitis, ulcerative Herpetic Gingivostomatitis Vesicles within the oral cavity Herpetic stomatitis, ulcerative

• It is caused predominantly by HSV-1 and affects mainly children. • Prodromal symptoms, such as fever, anorexia, irritability, malaise and headache. • The disease presents as numerous pin-head vesicles, which rupture rapidly to form painful irregular ulcerations covered by yellow–grey membranes. • Halitosis (bad mouth odor) and refusal to drink are usual concomitant findings Measles Measles The rash on the face and neck behind the ear. The rash is often first seen in these areas. Measles Koplik's spots Measles

• It is characterized by typical maculopapular rash which starts behind the ears and on the face. Then, it spread downwards to the trunk and feet. • Koplik’s spots are pathognomonic. They appear as grayish white lesions on buccal mucosa. • Treatment is symptomatic and complications are mainly respiratory and neurological. Roseola infantum Roseola infantum

Roseola Infantum

• A mild, contagious illness, is most common in children age 6 months to 2 years caused by human herpes virus-6. • The symptoms are mild respiratory illness, followed by a high fever (which can trigger seizures) for several days. • Fevers abruptly end and are followed by a rash of small, pink, flat, or slightly raised bumps on the trunk, then the extremities.

Scarlet Fever

• Sometimes a rough, red rash accompanies strep throat. This is known as scarlet fever. The rash begins on the chest and abdomen and spreads all over the body, accompanied by a strawberry- looking tongue and high fever. • Without treatment, it can lead to rheumatic fever and, in rare cases, heart damage. That's why scarlet fever was once a dreaded childhood illness. Today, it is easily cured with antibiotics.

Kawasaki Disease

Kawasaki disease Kawasaki disease

Kawasaki Disease

• Kawasaki disease is a rare and mysterious ailment that strikes children under age 5. • The symptoms include a high fever, patchy rash, swelling and redness of the hands and feet, non purulent conjunctivitis, and fissured red lips. • Without treatment, the illness can damage the heart and may be fatal due to coronary vasculitis.

Chicken pox rash Chicken pox rash

• Note that the chicken pox rash is very different from measles. • There are many distinct spots at different stages from erythematous papules (red spots) to vesicles with fluid in them, ulcers and scabs. Chickenpox, Varicella Chickenpox, Varicella

• Very contagious, chickenpox spreads easily, leaving an itchy rash and red spots or blisters all over the body. • The rash appears in successive crops, is centripetal in distribution and pleomorphic. • The rash is mainly papulovesicular. • Complications include secondary infected lesions, pneumonia, and neurological problems e.g.acute cerebellar ataxia Mumps Mumps

• A viral illness that often causes little symptoms, but when it does, the classic sign is swollen glands between the ear and jaw. • The swelling is better seen than felt, to be differentiated from a lymph node swelling. • Despite high vaccination rates, recent outbreaks have infected thousands of people in some countries.

Hemophilia, hemarthrosis Hemophilia, hemarthrosis

• It is an X-linked recessive disorder characterized by bleeding, easy bruising, large hematomas, and hemarthrosis. • Treatment is by replacement therapy using fresh frozen plasma, cryoprecipitate, and or factor VIII concentrate.

Purpura fulminans Purpura fulminans Purpura fulminans

• This is large ecchymoses with irregular shapes evolving into hemorrhagic bullae and then into black necrotic lesions. • Causes include sepsis (e.g. meningococcal), malignancy and massive trauma. • It carries a high mortality rate and intensive care management is urgently needed. Henoch Schonlein purpura Henoch Schonlein purpura Henoch Schonlein purpura

• The characteristic skin lesion is a purpuric rash involving the lower limbs and buttocks. • It is a vasculitis with a normal platelet count. • Other features include arthritis, abdominal pain and nephritis. • Most cases recover within few weeks. Systemic lupus erythematosus, malar rash Systemic lupus erythematosus, malar rash Systemic lupus erythematosus, malar rash

• A multisystem autoimmune disease characterized by malar rash, photosensitivity, mouth ulcers, arthritis, nephritis, pericarditis.. etc • Treatment is by anti-inflammatory drugs and corticosteroids.

Hives (Urticaria)

Hives (Urticaria) Hives (Urticaria)

• It is a common allergic manifestation. • Clinically, there is itching, erythematous rash with wheals, and edema around the eyes and mouth. One serious complication is laryngeal edema and airway obstruction. • Treatment is by SC or IM adrenaline and systemic steroids. • Medications, food additives, and temperature extremes, are some causes of hives. Malnutrition - Kwashiorkor Malnutrition - Kwashiorkor Malnutrition - Kwashiorkor

• A common complication of faulty weaning by a low protein high carbohydrate food. • Constant features include edema, growth failure, mental changes and disturbed muscle to fat ratio. Other important features include hair and skin changes. • Complications include hypoglycemia, hypothermia, electrolyte disturbances and serious infections.

Malnutrition - Marasmus Malnutrition - Marasmus Malnutrition - Marasmus

• A severely malnourished (marasmic) infant also has severe diarrhea and dehydration. Note how wasted he is, ribs are well seen. Malnutrition and severe diarrhea often go together. Sunken eyes are from dehydration. Marasmic Kwashiorkor Marasmic Kwashiorkor

• A severely malnourished child with features of both marasmus and Kwashiorkor. • The features of Kwashiorkor are severe edema of feet and legs and also hands, lower arms, abdomen and face. • There are also signs of marasmus, wasting of the muscles of the upper arms, shoulders and chest so that the ribs are well seen.

Rickets, chest deformity Rickets

• Clinical features include large head, rosary beads( enlarged costochondral junction), Marfan sign, fractures, and limb deformities (bow leg and knock knee). • Treatment is by vitamin D therapy for deficiency rickets. Dehydration, loss of skin turgor Dehydration, loss of skin turgor

• This child is severely dehydrated. The eyes are sunken and the skin pinch of the abdominal skin is going back very slowly, taking more than 2 seconds Severe dehydration, sunken eyes Dehydration

• This infant had severe diarrhea. After about 10 watery stools over 5 hours, the child became drowsy and the eyes are sunken. • The most accurate measure of dehydration is the degree of weight loss during the diarrheal illness. • The history and examination are used to assess the degree of dehydration: – No clinically detectable dehydration, only thirst (usually <5% loss of body weight) – Clinical dehydration (usually 5-10%) – Severe dehydration and shock (usually >10%).

Dehydration

• Dehydration and its complications are the usual cause of death from gastroenteritis. • Clinical features of dehydration in infants include depressed fontanelle, sunken eyes , dry tongue , loss of skin turgor, and acute weight loss. • Infants are at particular risk of dehydration because of their greater surface area to weight ratio and higher basal fluid requirement.

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