MME -303 Child Health Indira Gandhi National Open University School of Health Sciences Block 6 CHILDHOOD MORBIDITY UNIT 28 Common Paediatric Problems 5 UNIT 29 Cardiovascular, Haematological and Renal Disorders 24 UNIT 30 Gastrointestinal, Parasitic and Neurological Disorders 61 UNIT 31 Tuberculosis 90 UNIT 32 HIV/AIDS 106 UNIT 33 Common Paediatric Emergencies 119 UNIT 34 Common Paediatric Surgical Problems 130 PROGRAMMECORE TEAM Dr. I.C. Tiwari Dr. (Mrs.) Kamala Ganesh Dr. L.N. Balaji Dr. S.B. Arora Dr. Ruchika Kuba Sr. Consultant, UNICEF Director Professor and Head of Chief, Planning Division Course Coordinator Course Coordinator New Delhi O&G Deptt., MAMC, New Delhi UNICEF, New Delhi SOHS, IGNOU, New Delhi SOHS, IGNOU, New Delhi Dr. S.C. Chawla Dr. Sidharth Ramji Prof. (Col.) P.K. Dutta Dr. T.K. Jena Director Professor and Head of Professor, Deptt. of Paediatrics Programme Coordinator Course Coordinator PSM Deptt., LHMC, New Delhi MAMC, New Delhi SOHS, IGNOU, New Delhi SOHS, IGNOU, New Delhi COURSE REVISION TEAM (1st Revision) Dr. Neena Raina Dr. Harish Kumar Dr. M.S. Prasad Prof. A.K. Agarwal Dr. Ruchika Kuba Technical Officer, WHO Consultant Paediatrics, Head, Deptt. of Paediatrics Director, SOHS Sr. Lecturer and Course SEARO Office, New Delhi D.D.U. Hospital, New Delhi Safdarjang Hospital, IGNOU, New Delhi Coordinator New Delhi SOHS, IGNOU, New Delhi Dr. Siddharth Ramji Dr. A.K. Patwari Dr. T.K. Jena Professor, Deptt. of Peadiatrics National Professional Officer, Dr. Piyush Gupta Reader and Programme LNJP and MAMC, Delhi WHO Nirman Bhawan, Reader, Deptt. of Paediatrics Coordinator New Delhi GTB Hospital and UCMS SOHS, IGNOU, New Delhi New Delhi COURSE REVISION TEAM (2nd Revision) Dr. Siddharth Ramji Dr. M.S. Prasad Dr. (Mrs.) Lalitha Kailash Dr. (Mrs.) Jayam Subramanium Dr. A.K. Agarwal Professor, Deptt. of Peadiatrics Head, Deptt. of Paediatrics Professor, Deptt. of Peadiatrics Ex. Professor, Professor, SOHS, IGNOU, LNJP and MAMC, Safdarjang Hospital, GMC, Thiruvananthapuram, Deptt. of Peadiatrics New Delhi New Delhi New Delhi Kerala Madras Medical College, Chennai Dr. T.K. Jena Dr. S. Aneja Dr. Vinod Anand Dr. B.D. Bhatia Professor and Programme Professor, Deptt. of Peadiatrics Professor, Deptt. of Peadiatrics Professor, Deptt. of Peadiatrics Dr. S. B. Arora Coordinator LHMC, New Delhi LHMC, New Delhi IMS,BHU, Varanashi, U.P. Professor & Director, SOHS SOHS, IGNOU, New Delhi IGNOU, New Delhi COURSE REVISION TEAM (3rd Revision) Dr. Harish Chellani Dr. Anju Seth Dr. Neelam Verma Dr. A. P. Dubey Dr. T.K. Jena Professor and Head Director Professor, Professor and Head, Professor and Head, Professor, Deptt. of Paediatrics Deptt. of Peadiatrics Deptt. of Peadiatrics Deptt. of Peadiatrics School of Health Sciences VMMC & Safdarjung Hospital, LHMC, New Delhi Patna Medical College & LNJP and MAMC, IGNOU, New Delhi New Delhi-110029 Hospital, Patna, New Delhi Bihar-800004 BLOCKPREPARATIONTEAM Writers Unit 28 Unit 29-31 Unit 32 Format Editor Dr. Satinder Aneja Dr. Satinder Aneja Dr. Jagdish Chandra Dr. T.K. Jena Director Professor, Director Professor, Director Professor, Deptt of Paediatrics, Professor and Deptt of Paediatrics, Deptt of Paediatrics, LHMC, New Delhi Programme Coordinator LHMC, New Delhi LHMC, New Delhi Dr. Lalitha Kailash (Pre-revised) SOHS, IGNOU, New Delhi Dr. Jagdish Chandra (Pre-revised) Prof. Deptt of Paediatrics, Director Professor, Thiruvananthapuram Deptt of Paediatrics, LHMC, New Delhi Unit 33 Dr. Rajiv Chadha Director Professor, Deptt of Paediatric Surgery, LHMC, New Delhi CO-ORDINATION Dr. S. B. Arora Dr. T.K. Jena Professor & Director, SOHS Professor and Programme Coordinator IGNOU, New Delhi SOHS, IGNOU, New Delhi PRINTPRODUCTION Mr. Ajit Kumar Section Officer (Pub.), SOHS IGNOU, New Delhi March, 2019 © Indira Gandhi National Open University, 2019 ISBN- All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other means, without permission in writing from the Indira Gandhi National Open University. Further information about the School of Health Sciences and the Indira Gandhi National Open University courses may be obtained from the University’s office at Maidan Garhi, New Delhi-110 068, India. Printed and published on behalf of the Indira Gandhi National Open University, New Delhi, by Prof. S. B. Arora, Director, School of Health Sciences. Lasertypeset by : Rajshree Computers, V-166A, Bhagwati Vihar, (Near Sec. 2, Dwarka), Uttam Nagar, New Delhi-110059 Printed at: BLOCK 6 INTRODUCTION This block provides you an overview of common paediatric systemic illnesses and emergencies. Unit 28 will take you through the evaluation of common childhood problems. Cardiovascular, haematologic and renal disorders are discussed in Unit 29, while gastrointestinal, liver and neurologic problems are presented in Unit 30. Tuberculosis and HIV are emerging childhood problems which are discussed in Unit 31 and Unit 32. Paediatric emergencies such as resuscitation, poisoning, accidents, etc. are reviewed in Unit 33 of this block. Finally, the Unit 34 on common paediatric surgical problems gives you an insight about the possible surgical procedures. ChildhoodMorbidity 4 UNIT 28 COMMON PAEDIATRIC PROBLEMS Structure 28.0 Objectives 28.1 Introduction 28.2 Child with Fever 28.2.1 Common Causes of Fever 28.2.2 Acute Fever 28.2.3 Fever of Unknown Origin (FUO) 28.3 Child with Rash 28.4 Child with Jaundice 28.5 Child with Sore Throat 28.6 Child with Ear Infection 28.7 Common Skin Disorders 28.7.1 Bacterial Infections 28.7.2 Fungal Infections 28.7.3 Parasitic Infections 28.8 Let Us Sum Up 28.9 Key Words 28.10 Answers to Check Your Progress 28.0 OBJECTIVES After reading this unit, you will be able to: diagnose and treat various types of viral exanthematous illnesses; diagnose common febrile illnesses and plan investigations of a patient with fever of unknown origin; manage a child with jaundice; differentiate self-limiting benign causes of sore throat from potentially serious infections such as diphtheria; and identify and manage common skin disorders in children. 28.1 INTRODUCTION In clinical practice, a child presents with a symptom rather than a disease. Therefore, a step wise approach is required to make differential diagnosis and plan investigations. In this unit, a symptom-wise approach is used to enable you to make a clinical diagnosis of some common problems. Other common conditions are. described in brief. You are required to refer to standard text books for the detailed discussion of these disorders. 5 ChildhoodMorbidity 28.2 CHILD WITH FEVER Fever is the commonest presenting symptom in children. Fever is defined as elevation of body temperature in response to a pathological stimulus. Conventionally temperature >38°C is called fever. Fever greater than 41.5°C is called hyperpyrexia and warrants aggressive antipyretic treatment because of risk of irreversible organ damage, Children presenting with fever can be di\!ided into three groups: (i) acute fever with obvious focus such as tonsillitis or pneumonia etc. (ii) acute fever with no localizing sign or non-specific signs and (iii) prolonged fever of unknown origin. It is the latter two groups which pose diagnostic problem. While evaluating the patient with fever the first important thing to consider is the age of the patient. Acute fever in an infant less than 2 months should always arouse suspicion of serious bacterial infection presence of petechial haemorrhages at any age is also indicative of serious illness and necessitates hospitalization. The other important consideration is duration of fever. Important causes of fever of short duration (2 weeks) and prolonged fever are listed in Table 28.1. The common causes of acute fever are malaria, viral illness( may also cause upper respiratory infection and diarrhea) and bacterial infections such as typhoid fever. 28.2.1 Common Causes of Fever The common causes of fever are given in Table 28.1. We shall learn more about these causes in the subsequent sub-sections. Table 28.1: Common Causes of Fever in Children Causes of fever of short duration Prolonged fever ( <2 weeks) ( >2 weeks) Infections Malaria Typhoid. Respiratory infection e.g. Kala-azar Tonsillitis Malaria Pneumonia Tuberculosis Otitis Media UTI Viral Exanthem Bacterial endocarditis Typhoid fever Abscess in liver Urinary Tract Infection (UTI) Brucellosis Heat hyperpyrexia Infectious mononucleosis Occult pyogenic infection Connective tissue disorders e.g. abscess Rheumatoid arthritis 6 Common Paediatric Meningitis SLE, Kawasaki disease Problems Neoplastic Condition e.g. Leukaemia, lymphoma Others Drug fever Thyrotoxicosis Immune deficiency-HIV Diabetes Insipidus 28.2.2 Acute Fever Evaluate for any focus of infection. Determine whether the child is seriously ill? A sick child has one or more of following symptoms and signs: Symptoms Signs Lethargy “sick” or toxic look Inability to suck lethargy/poor tone Irrititability weak cry Drowsiness tachypnoea poor peripheral perfusion The fundamental basis of diagnosis is to localize the infection by careful history and clinical examination. It should also be remembered that in children disease develops over hours and days and a single examination may not provide the diagnosis. Where there is a doubt, the child should be hospitalized and reexamined. In a small but significant proportion of children no identifiable cause of fever is found even after detailed examination. This problem is more common in infants and toddlers. The common causes of acute fever without obvious focus are viral illness, malaria, otitis media, typhoid fever, occult bacteremia. The diagnosis can be then established by (i) obvious focus such as tonsillitis or pneumonia etc. (ii) acute fever with no localizing sign or non-specific signs and (iii) prolonged fever of unknown origin. It is the latter two groups which pose diagnostic problem. In areas endemic for malaria, empirical therapy for malaria may be started. In case laboratory investigations are not available treatment is often based on clinical diagnosis. Occult bacteremia implies presence of bacteria in the blood stream with minimal clinical signs.