Đang tải... (xem toàn văn)
(BQ) Part 2 book Ghai essential pediatrics has contents: Otolaryngology, disorders of respiratory system, endocrine and metabolic disorders, central nervous system, disorders of cardiovascular system, skin disorders, neuromuscular disorders, childhood malignancies,... and other contents.
Otolaryngology Sandeep Samant, Grant T Rohman, Jerome W Thompson DISEASES OF THE EAR Otitis Media Otitis media is a common early childhood infection Anatomic features that make young children particularly susceptible to ear infections include shorter, more horizontal and compliant eustachian tubes and bacterial carriage in the adenoids Other risk factors include expo sure to cigarette smoke, overcrowding, bottlefeeding, cleft palate, Down syndrome, allergy and immune dysfunction These risk factors contribute to the pathophysiology of the two common varieties of otitis media, acute otitis media and otitis media with effusion Acute Otitis Media Acute otitis media (AOM) in children tends to have a bimodal age distribution, with children between ages and 24 months and to yr at greatest risk Etiology The most common organisms causing AOM are Streptococcus pneumoniae and Haemophilus influenzae, accounting for approximately 65% cases; 15% are caused by Moraxell a catarrh alis, Streptococcus pyogenes and Staphylococcus aureus Respiratory viruses play an important role in initiating otitis media and may be the only pathogens in some cases, since 20% of middle ear aspirates are sterile Diagnosis AOM is characterized by the rapid onset of symptoms, which may be local, e.g otalgia or ear tugging, and/or systemic, e.g fever or crying Older children may report impaired hearing History of recent upper respira tory tract infection is common Otoscopic examination reveals a red and bulging tympanic membrane with redu ced mobility as measured by either tympanometry or insufflation through the otoscope (pneumatic otoscopy) Rupture of the drum with ear discharge (suppuration) may have already occurred, in which case the ear canal contains an opaque yellow-green or reddish-brown fluid Cleaning of this fluid usually reveals an intact drum, as the rupture is small and closes promptly after spontaneous perforation The diagnosis of AOM is considered certain if all of the following criteria are met: (i) rapid onset; (ii) signs of middle ear effusion; and (iii) signs and symptoms of middle ear inflammation Tre atment Antimicrobial therapy is recommended However, in some cases children may qualify for a trial of observation (Table 13.1) Amoxicillin should be the first line therapy for AOM Higher doses (80-90 mg/kg/day) may be considered where streptococcal resistance is endemic Agents with �-lactamase resistance (e.g amoxicillin-clavulanic acid, cefaclor, cefuroxime or newer cephalosporins) are useful second-line drugs Initial Table 13.1: Criteria for choice of treatment or observation in children with acute otitis media Age Diagnosis certain Diagnosis uncertain 25 dB (Fig 13.2) Other indications of tube placement in OME are speech delay, altered behavior, major sequelae such as otitic meningitis or impending cholesteatoma formation from tympanic membrane retraction Improve ment in hearing and ear discomfort is immediate Mean time before extrusion is usually between 12 and 18 months Insertion of longterm tubes ( of T-tube design) or adenoidectomy may be considered in patients with recurrent or persistent symptomatic effusion T-tubes have been associated with tympanic membrane perforation Earplugs are recommended while the tubes are in place to avoid entry of water into the middle ear space Chronic Suppurative Otitis Media (CSOM) Ear drainage that persists for longer than weeks is generally due to chronic inflammation of the middle ear space or mastoid air cells Chronic suppurative otitis media (CSOM) invariably presents with tympanic membrane perforation, which allows otorrhea CSOM most often results from neglected episodes of AOM and is therefore more common in children with inadequate access to health care It most often occurs in the first five years of life as eustachian tube dysfunction plays a central role in the pathophysiology Clwlesteatoma, a sac of squamous epithelium extending from the tympanic membrane into the middle ear, also Fig 13.2: Tympanostomy tube in situ in the anteroinferior quadrant of the tympanic membrane (Courtesy, Textbook of ENT, Hazarika) _o_t_o_,a_ry_n_g_o,_o_ g_y presents with a chronically draining ear Most cholesteatoma is acquired It remains unclear whether a cholesteatoma arises from extension of a tympanic membrane retraction pocket, or from aberrant inward migration of normal epithelium Rarely, it may be congenital, arising de nova through the eustachian tube by passage of neonatal epithelium Though not malignant, cholesteatoma may cause serious compli cations by slow expansion and local destruction Etiology The most commonly isolated organism is Pseudomonas aeruginosa; other organisms include Staphylo coccus aureus, Proteus spp, E coli and anerobes Fungi, especially Aspergillus and Candida spp., may be important Diagnosis Chronic ear discharge is the hallmark of CSOM Otoscopy reveals perforation of the tympanic membrane (Fig 13.3) A chronically draining ear may also be seen with cholesteatoma, which is a sac of squamous epithelium extending from the tympanic membrane into the middle ear Most cholesteatoma is acquired, although whether it arises from extension of a tympanic membrane retraction pocket, or from aberrant inward migration of the normal eardrum epithelium, remains unclear Rarely, the choles teatoma may be congenital, arising de nova in the middle ear space Though not malignant, cholesteatoma may cause serious complications by slow expansion and local destruction These complications are discussed further in the next section Treatment Medical therapy consists primarily of topical antibiotics and aural toilet Topical quinolones appear to be effective and safe Complicated infections and/ or any signs of systemic involvement require the use of systemic antibiotic therapy Parents should be instructed to avoid water exposure Secondary fungal otitis externa is a complication of topical antibiotic treatment Otolaryn gology referral is necessary to rule out cholesteatoma Surgery is usually indicated for cases of CSOM that not respond to conservative treatment Surgical therapy involves repair of the tympanic membrane perforation (tympanoplasty) with or without mastoidectomy If cholesteatoma is suspected, ear exploration via mastoi dectomy and cholesteatoma removal is mandatory The primary goal of surgical therapy for cholesteatoma is to create a 'safe ear' by removal of all cholesteatoma Hearing preservation is a secondary goal Complications of Otitis Media Untreated otitis media may cause serious complications, which are classified as either intracranial or extracranial (Table 13.2) Complications of AOM are more common in young children, while complications of CSOM with or without cholesteatoma are common in older children The most common complication of CSOM is hearing loss, which may affect language development and school performance The hearing loss is usually conductive and results from middle ear edema and fluid and tympanic membrane perforation Sensorineural hearing loss may rarely occur due to direct extension of inflammatory mediators into the inner ear Meningitis is the most common intracranial complication of both acute and chronic otitis media Furthermore, AOM is the most common cause of secondary meningitis Pneumococcal meningitis is the most common cause of acquired sensorineural hearing loss in children The mortality rate from otitic meningitis has decreased significantly in the postantibiotic era and with the use of streptococcal vaccines Brain abscess is a potentially lethal complication Unlike meningitis, which is caused more frequently by AOM, brain abscesses result almost exclusively from CSOM Therapy with broad spectrum parenteral antibiotics is begun immediately and surgical drainage considered Thrombosis of the sigmoid or transverse sinus is another important intracranial complication Patients typically Table 13.2: Complications of otitis media• lntracranial Meningitis Epidural abscess Dural venous (sigmoid sinus) thrombosis Brain abscess Otitic hydrocephalus Subdural abscess Extracranial Fig 13.3: Otoscopy in a child with chronic suppurative otitis media showing subtotal central perforation (Courtesy, Textbook of ENT, Hazarika) Acute coalescent mastoiditis Subperiosteal abscess Facial nerve paralysis Labyrinthinitis or labyrinthine fistula *Listed from most to least common n _ - E_s_s_e_ _ t_ia_i_P_e_d_ i_a t_ r_ic_s present with headache, malaise and high spiking fever in a 'picket fence' pattern Treatment involves parenteral antibiotics and surgical drainage of the mastoid fungal spores and filaments Aspergillus and Candida are the most common pathogens Aural toilet and a topical antifungal (e.g clotrimazole) are curative Acute coalescent mastoiditis This results from the spread of Otic furunculosis is an exquisitely painful, superficial abscess in the outer portion of the ear canal, typically from S aureus Oral antistaphylococcal antibiotics and anal gesics bring about prompt relief Incision and drainage may be necessary infection into the mastoid bone The entity should be differentiated from fluid effusion within mastoid air cells, which is sometimes mistakenly reported radiologically as 'mastoiditis' Such opacification is commonly seen with AOM or OME, is readily apparent on CT and is of little clinical significance Coalescent mastoiditis, on the other hand, presents with postauricular erythema, tenderness, and edema The auricle is displaced inferiorly and laterally The CT scan shows fluid and breakdown of the wall separating the mastoid air cells Untreated, coalescent mastoiditis may spread externally, leading to the formation of subperiosteal or deep neck abscesses Acute coalescent mastoiditis should initially be treated with parenteral antibiotics directed against the afore mentioned pathogens associated with AOM If mastoiditis is superimposed on a chronically draining ear, coverage should be added for gram-negative and anerobic organisms Surgery in the form of cortical mastoidectomy with tympanostomy tube insertion is indicated for cases with poor response to parenteral antibiotic therapy, presence of an abscess or an intracranial complication or acute mastoiditis in a chronic ear Other complications include labyrinthinefistula andfacial nerve paralysis Labyrinthine fistula, in which a choleste atoma has eroded into the inner ear, presents with vertigo and sensorineural hearing loss Facial nerve paralysis secondary to otitis media is treated with appropriate antibiotics and tympanostomy tube insertion If facial nerve paralysis is secondary to cholesteatoma, mastoi dectomy is indicated Otitis Externa Acute otitis externa (swimmer's ear) presents with itching, pain and fullness Erythema and edema of the ear canal and tenderness on moving the pinnae or tragus are diagnostic features Otorrhea is common Risk factors include swimming, impacted cerumen, hearing aid use, eczema or trauma from foreign objects (hairpins or cotton swabs) The etiologic agents of otitis externa include P aeruginosa, Staphylococcus, Proteus, E coli, Aspergillus and Candida spp Treatment consists of ear canal culture, cleaning and topical antibiotic drops Topical antibiotics have clinical cure rates up to 80% If edema is significant, ribbon gauze or a 'wick' may be placed in the external auditory canal to stent it open for drop delivery Oral antibiotics are reserved for failure to improve and complications Otomycosis or fungal otitis externa is most common in humid weather and presents with pain and pruritus These opportunistic infections are frequently seen subsequent to treatment of a bacterial infection Examination reveals Eczematous or psoriatic otitis externa describes a group of inflammatory conditions in which there is drainage, pruritis and/ or scaling of the ear canal skin Underlying causes include contact dermatitis, atopic dermatitis and seborrheic dermatitis is a rare invasive infection of the external auditory canal cartilage and bone Immunocom promised children (acquired immunodeficiency syn drome, leukemia, diabetes mellitus, immunosuppression after organ transplant) are at risk Pseudomonas aeruginosa is the most common etiology Invasive fungal species, especially Aspergillus, are also seen The external auditory canal is tender and facial or scalp necrosis may arise, with or without cranial nerve abnormalities Diagnosis is confirmed with CT and MRI scan and/ or scintigraphy for osteomyelitis of the temporal bone Aggressive surgical debridement and parenteral antibiotics and/ or antifungals for 4-6 weeks are required Treatment response may be monitored with serial Gallium67 bone scans Malignant otitis externa Hearing Loss Early detection of hearing loss in children is imperative Unrecognized early hearing loss can impede development of speech, language and cognitive skills Separate differen tial diagnoses exist for deficits of both the conductive and sensorineural components of the hearing mechanism Hearing loss in children can be classified as either congenital or acquired Conductive Hearing Loss Any process that interferes with the conductive mechanism of the ear canal, tympanic membrane, or ossicles may cause a conductive hearing loss The most common pedia tric cause of conductive lost is otitis media with effusion and is typically of mild to moderate severity Several congenital syndromes may also be associated with middle ear abnormalities, such as Apert, Crouzon and Treacher Collins syndromes Sensorineural Hearing Loss Sensorineural hearing loss is caused by a lesion of the cochlea, auditory nerve or central auditory pathway SNHL can be acquired or congenital, both being equally common The most common postnatal cause of acquired sensorineural hearing loss is meningitis, while the most common prenatal cause is intrauterine infection (e.g TORCH infections, syphilis) Other causes of acquired _o_t_ o_ ,a_ry_n_g_o _,o_ g_y hearing loss include prematurity, hyperbilirubinemia, perinatal hypoxia, acquired immunodeficiency syndrome, head trauma and ototoxic medications (aminoglycosides, loop diuretics) Congenital causes of sensorineural hearing loss are of syndromic and nonsyndromic types Although 70% of congenital hearing loss is nonsyndromic, over 300 genetic syndromes are associated with SNHL Common syndromes include Pendred syndrome (euthyroid goiter), Jervell and Lange-Nielsen syndrome (prolonged QT waves, syncope), Usher syndrome (retinitis pigmentosa and blindness), Alport's syndrome, branchio-oto-renal syndrome, neuro fibromatosis and Waardenburg syndrome Multiple chromosome loci and at least 65 genes associated with genetic hearing loss have been identified Mutations in a single gene, GJB2, may be responsible for up to 50% of nonsyndromic congenital hearing loss GJB2 encodes the protein connexin 26, which is widely expressed in cells of the inner ear Screening tests for this mutation are available Neonatal Screening All neonates with risk factors for hearing loss should be screened with an oto-acoustic emission test or an auditory brainstem response The use of clinical indicators to focus hearing screens will miss as many as 50% of all cases of impairment Hence universal newborn hearing screen programs are now commonplace in the United States and Europe The importance of neonatal screening cannot be overemphasized Infants in whom treatment for hearing loss is initiated by months of age are able to maintain language and social development in line with their phys ical development This is in contrast to those whose hearing loss is identified after months of age A limitation of newborn screening is that some forms of early-onset hearing loss are not apparent at birth A United States Joint Committee on infant hearing has identified 11 risk indicators that should prompt continued monitoring of hearing status even in the face of normal neonatal screens (Table 13.3) Screening in Older Children Clinical evaluation of hearing at routine well child assess ments is critical for early detection of hearing impairment Examination should include otoscopy with attention to middle ear pathology Doubtful cases are referred for detailed audiologic evaluation so that timely intervention may begin Multiple techniques exist to assess hearing sensitivity and are selected based on the age and the abilities of the child For younger children unable to understand instruc tions, visual-reinforcement audiometry is performed Pure tone audiometry is possible in children older than yr Tympanometry may be performed in nearly all children to assess ear drum mobility Table 13.3: Indications for continued hearing monitoring in children with normal hearing on neonatal screening Caregiver concern regarding hearing, speech, or develop mental delay Family history of childhood hearing loss Neonatal intensive care for >5 days or use of any of the following, regardless of duration: Extracorporeal membrane oxygenation, assisted ventilation, exposure to ototoxic antibiotic (gentamycin, tobramycin) or loop diuretics (furosemide) and hyperbilirubinemia requiring exchange transfusion In utero infections (CMV, rubella, syphilis, herpes, toxo plasmosis) Findings of a syndrome associated with hearing loss Postnatal infection known to cause hearing loss (e.g meningitis) Syndromes associated with progressive hearing loss (e.g neurofibromatosis) Neurodegenerative disorders (e.g Hunter syndrome, Friedreich ataxia) Head trauma Recurrent or persistent (�3 mo) otitis media with effusion Chemotherapy or head radiation Treatment of Hearing Loss Once diagnosed, treatment of hearing loss is based on the extent of deficit and the underlying pathology For very mild hearing loss, treatment may consist simply of preferential seating in school For mild to moderate conductive hearing loss, treatment options include tympanostomy tubes or, if a perforation is present, tympanoplasty Treatment of significant sensorineural hearing loss may require the use of hearing aids from as early as months of age The development of cochlear implants has rapidly reshaped the management of childhood hearing loss Bilateral cochlear implantation may be considered for infants as young as 12 months of age who have a profound bilateral hearing loss and may be considered even earlier if the hearing loss is due to meningitis If a child has never had auditory stimulus (secondary to profound congenital deafness), cochlear implantation before yr of age is crucial to develop the auditory cortex for sound awareness and speech development Sign language and deaf education programs should be considered for children who are not candidates for cochlear implantation DISEASES OF THE NOSE AND SINUSES Rhinitis Allergic Rhinitis Allergic rhinitis is an inflammatory disorder characterized by sneezing, itching, nasal obstruction and clear rhino- i i n _E_s_s_e_ _ _t ia_i_P_e_d_ _a _tr- c_s _ rrhea The pathophysiology involves an IgE-mediated reaction to a specific allergen Symptoms may be seasonal ('hay fever') or perennial Examination reveals a pale nasal mucosa, congested nasal turbinates and mucoid rhinor rhea Conjunctiva! itching and redness may be present Inhaled allergens (e.g pollen, spores and dust mites) are common causes Accurate diagnosis may require demonstration of eosinophilia in a nasal smear, or the use of skin/ serologic tests to show specific IgE response to allergens These tests establish the atopic etiology and help differentiate from other conditions with similar symptoms Treatment includes allergen avoidance, use of topical nasal steroid sprays for prevention and oral antihistamines for symptom relief The use of oral decongestants is controversial Topical decongestants should also generally be discouraged as they cause rebound congestion (short term) and chemical rhinitis or rhinitis medicamentosa (longterm) Viral Rhinitis Viral rhinitis or common cold is the most common cause of both nasal obstruction and rhinorrhea in children Children normally average between six and eight of these upper respiratory infections per year Malaise, low to moderate grade fever, nasal congestion and rhinorrhea are the presenting symptoms A number of different viruses can be responsible, including rhinovirus, influenza and adenovirus Treatment is symptomatic and involves antipyretics, saline nasal spray Use of oral decongestants and antihistamines are controversial A number of deve loped countries recommend annual influenza vaccination in children older than months Otitis media and sinusitis are frequent complications Diagnosis Acute rhinosinusitis typically presents as an episode of upper respiratory infection with worsening of nasal discharge and cough to 10 days after onset of symptoms A severe URI with fever (>38.5 ° C) and purulent rhinorrhea also meets the diagnostic criteria for acute sinusitis Chronic sinusitis is defined as symptoms of sinusitis lasting longer than 30 days Nasal obstruction, malaise and headache may all be features of chronic rhinosinusitis Imaging is not necessary and should be reserved for cases with complications and those being considered for surgery CT scan is superior to plain X-rays for imaging of paranasal sinuses (Fig 13.4) Allergic fungal sinusitis is an increasingly recognised condition in atopic, immunocompetent patients Older children and adolescents are most commonly affected The cause is hypersensitivity to fungal antigens This results in the form of chronic rhinosinusitis that requires surgical intervention Complications These include orbital or intracranial spread of infection Orbital complications most commonly result from direct extension from the ethmoids Early orbital complications manifest as periorbital (preseptal) cellulitis More severe complications include orbital abscess or cavernous sinus thrombosis Ophthalmoplegia, vision loss, and toxemia indicate a life-threatening infection of the cavernous sinus Intracranial complications (meningitis and abscesses) may also occur and are more commonly associated with frontal and sphenoid sinus infections Sinusitis Sinusitis can be classified as either acute or chronic The ethmoid and maxillary sinuses are the earliest to develop and are the ones most commonly infected in pediatric sinusitis The frontal sinuses may become involved only after 5-6 yr of life; isolated sphenoid disease is rare Risk factors associated with sinusitis include recurrent upper respiratory infections, allergic rhinitis, cystic fibrosis, immunodeficiency, ciliary dyskinesia, daycare attendance and exposure to tobacco smoke Ten-fifteen percent of upper respiratory tract infections are complicated by sinusitis A sinus infection should be considered in any child whose cold symptoms have not resolved by 7-10 days Etiology The most common isolates in acute sinus infec tions are pneumoniae, H influenzae and M catarrhalis The same bacteria are implicated in chronic sinusitis, as are aureus, anerobes and occasionally fungi The adenoid pad plays an important role in the pathophysiology of pediatric sinusitis since it may serve as a bacterial reservoir for the paranasal sinuses (Fig 13.4) Fig 13.4: Note the air fluid level in right maxillary sinus in a patient with maxillary sinusitis (Courtesy: Textbook of ENT, Hazarika) o_to_ 1_a_ry_n_g _o _1o_ g_y Treatment Although a significant number of acute sinusitis episodes will resolve spontaneously, treatment with antibiotics is preferred Therapy with amoxicillin is recommended for 10-14 days Longer courses and second line antibiotic agents are indicated for refractory infections Parenteral antibiotics are necessary for sinusitis with orbital or intracranial complications Other adjuvant mea sures include oral decongestants, mucolytic agents and topical nasal saline Topical decongestants may be used in sinusitis with complications Antihistamines are avoided due to their drying effect Antibiotics are also required for chronic sinusitis As most of these patients have already failed a course of standard-dose amoxicillin, initial therapy consists of coamoxiclav, high-dose amoxicillin or cefuroxime The duration of treatment is longer than for acute sinusitis, typically to weeks Patients with penicillin allergy may be treated with a macrolide antibiotic, although there is increasing resistance of pathogens to these agents Topical nasal steroids are occasionally useful for treatment Surgical intervention for acute sinusitis is limited to those with orbital or intracranial complications Surgery may be considered for patients with chronic sinusitis who have not responded to aggressive medical management or who show anatomical obstruction after maximal medical management and extensive medical workup with allergy testing and immune evaluation Adenoidectomy, to remove a potential bacterial reservoir for the sinuses, must be considered in younger children The indications for endoscopic sinus surgery include patients with sinonasal polyposis, cystic fibrosis, failure to improve despite one-month course of medical therapy and any orbital or cranial complication Nasal Obstruction Causes Chronic mouth breathing in children is generally caused by blockage of nasal airflow The site of nasal blockage is most often in the nasopharyngeal area due to adenoid hypertrophy Intranasal causes of obstruction include allergic rhinitis, recurrent sinusitis, nasal septum deviation, turbinate hypertrophy, nasal polyps and less commonly, neoplasms As a rule, bilateral nasal polyps not occur in normal children and their presence should prompt testing for cystic fibrosis Congenital causes of nasal airway obstruction include choanal stenosis or atresia, dermoid cysts, teratomas, encephaloceles, and pyriform aperture (bony opening to the nasal cavity in the skull) stenosis Diagnosis Adenoid enlargement should be suspected in children, usually older than yr, who present with nasal blockage, mouth breathing, sleep disturbance and chronic nasal discharge Examination must rule out nasal pathology such as septal deviation or polyposis Neonates with pyriform aperture stenosis may present with a single midline maxillary incisor A CT scan or X-ray confirms the diagnosis (Fig 13.5) Fig 13.5: Lateral radiograph of the neck showing adenoid hypertrophy occluding the nasopharyngeal airway in a 6-yr-old boy (Courtesy, Textbook of ENT, Hazarika) Treatment Adenoidectomy is recommended for symptomatic younger children Pubertal growth of the rnidface and regression of adenoid size tend to result in relief of adenoid-related nasal obstruction in children older than yr Pyriform aperture stenosis is treated with surgical drilling of the obstructing bony plates Treatment for sinonasal polyposis includes topical and systemic steroids for limited disease and surgical intervention for larger, obstructing polyps Surgery on the nasal septum should be avoided in pre pubertal children, as it may lead to retardation in rnidface growth and saddling of the nasal dorsum A conservative operation to correct a limited portion of the septum may be justified in a particularly symptomatic child Turbinate hypertrophy usually responds to treatment of allergy, though electrocautery may be used in refractory cases Eplstaxls Bleeding from the nose occurs frequently in children Most pediatric epistaxis occurs in the anterior portion of the nasal septum at a confluence of arterial vessels known as Little's area (Kiesselbach plexus) Local trauma, especially nose picking, is by far the most common cause of pediatric epistaxis Reduced ambient humidity also places the patient at risk Examination reveals prominent vessels in Little's area that bleed promptly when touched with a cotton-tipped probe Digital pressure by pinching the nose invariably stops the bleeding Avoidance of nose picking, application of an antibiotic ointment for lubrication and, - - Essential Pediatrics for refractory cases, cauterization with topical silver nitrate or electrocautery are curative Bleeding disorders must be suspected in children with suggestive family history, a history of frequent bleeding from other sites, or any nasal bleeding which does not respond in the usual fashion Less frequent causes of recurrent epistaxis include juvenile nasopharyngeal angiofibroma and hereditary hemorrhagic telangiectasia The former is a benign, vascular tumor occurring exclusively in adolescent males that can cause profuse, brisk bleeding Hereditary telan giectasia also known as Osler-Weber-Rendu syndrome, is a genetic defect in blood vessel structure resulting in arteriovenous malformations Patients may suffer from severe, recurrent epistaxis, as well as gastrointestinal bleeds and pulmonary hemorrhage Choanal Atresia Congenital failure of the nasal cavities to open into the nasopharynx is called choanal atresia It results from failed resorption of the buccopharyngeal membrane either unilaterally or bilaterally or even partial with a severe stenosis As neonates are obligate nasal breathers for months, bilateral choanal atresia presents immediately afterbirth with respiratory distress The affected baby cycles between silent cyanosis and crying Suckling immediately precipitates cyanosis Bilateral atresia can present as part of the CHARGE association, consisting of coloboma, heart abnormalities, choanal atresia, retardation of growth and development, genitourinary defects and ear anomalies Unilateral choanal atresia is a more indolent process and may present later in childhood with unilateral nasal discharge or blockage Atresia typically manifests when the opposite nasal passage becomes blocked due to rhinitis or adenoid hypertrophy Diagnosis Inability to pass an French catheter can aid in diagnosis Flexible nasal endoscopy confirms the diagnosis CT scan demonstrates the atretic plate thickness and differentiates between bony and membranous atresia Treatment Bilateral choanal atresia requires urgent management by inserting a finger in the baby's mouth and depressing the tongue down and forward away from the back of the throat This should be replaced with a plastic oropharyngeal airway or a McGovern open-tip nipple Failure of these measures may necessitate intubation or tracheostomy Treatment of choanal atresia is surgical The two primary approaches are transpalatal and transnasal Transnasal endoscopic repair is often attempted first as it is less invasive Transpalatal repair, which involves removal of the posterior hard palate, is often reserved for failed endoscopic repair Stents are placed in the nasal passages to prevent restenosis and are typically left in place for to weeks postoperatively DISEASES OF THE ORAL CAVITY AND PHARYNX Inflammatory Disorders Recurrent aphthous stomatitis is a common pediatric disorder that presents as painful white ulcers of variable size on the oral mucosa The exact etiology is unknown The ulcers resolve spontaneously over several days If symptomatic management does not suffice, topical steroids and rarely, systemic steroids are employed, but may require intravenous fluids for dehydration Herpetic stomatitis presents in children with small, painful vesicles that evolve into gray pseudomembranous mucosal ulcers Antiviral medications may be used to hasten recovery, though the lesions usually heal spon taneously within 10-14 days Once again intravenous fluids may be required Oral ca11didiasis (thrush) appears as small, white, curd-like lesions on the tongue and oral mucosa In children under age months or those on antibiotics, it is a benign finding It can also be related to systemic diseases such as diabetes or immunodeficiency Oral antifungals are effective Congenital Disorders A11kyloglossia (tongue tie) is a limitation of anterior tongue mobility caused by a congenitally short lingual frenulum This condition is not related to speech impairment Cleft palate may appear with or without cleft lip and can cause serious feeding difficulties The etiology is multi factorial Treatment should include staged reconstruction of the lip and palate defects and multidisciplinary management Micrognathia (small mandible), if severe, may displace the tongue posteriorly and cause respiratory distress in the neonate Congenital micrognathia is most commonly seen with the Pierre Robin sequence, in which patients also have cleft palate and glossoptosis If the micrognathia is severe, the neonate may require tracheostomy to secure the airway Macroglossia may be idiopathic or associated with syn dromes such as Down syndrome, Beckwith-Wiedemann syndrome and neurofibromatosis If significant, the enlarged tongue may cause drooling, speech impairment and airway obstruction Lingual thyroid may present as a posterior midline tongue mass and is caused by an abnormal descent of the thyroid from the tongue base in utero It may present with neonatal respiratory distress and may be associated with a thyroglossal dust cyst As lingual thyroid often represents the only functioning thyroid tissue, its removal may necessitate chronic thyroid hormone supplementation Sore Throat Viral pharyngitis is very common and is caused by a number of different pathogens including adenovirus, _o_t_o1_a_ry_g_ no_ _1o_g_y enterovirus, coxsackievirus and parainfluenza virus It typically presents with nonexudative pharyngeal erythema and tender cervical adenopathy Upper respiratory complaints (rhinorrhea, nasal obstruction, cough, fever) are common Treatment is supportive, as this is nearly always self-limited Infectious mononucleosis, caused by the Epstein Barr virus, presents with sore throat, gray pharyngeal exudate and soft palate edema Patients show significant cervical lymphadenopathy and hepatosplenomegaly Monospot or Paul-Bunnell tests are useful screening tests (only 40% accurate) and antibody titer confirms the diagnosis Medical treatment is supportive and may include steroids for respiratory difficulty or severe dysphagia Acute bacterial pharyngotonsillitis is caused by group A �-hemolytic streptococci Less common pathogens include nongroup A streptococcus, S aureus (Fig.13.6), H influ enzae, M catarrhalis, diphtheria, gonococci, chlamydia and mycoplasma Streptococcal pharyngitis presents as bil ateral tonsil hypertrophy and erythema with characteristic exudate To distinguish between viral and bacterial pharyngotonsillitis, a rapid strep test should be obtained A negative result should be confirmed by throat culture Treatment is with a ten-day course of penicillin VK or a first-generation cephalosporin Both suppurative and nonsuppurative complications can result from incom pletely treated streptococcal pharyngitis Non-suppura tive complications include scarlet fever, acute rheumatic fever and poststreptococcal glomerulonephritis Suppura tive complications include peritonsillar, para-pharyngeal or retropharyngeal abscesses Peritonsillar abscess typically presents with a muffled voice, trismus and decreased oral intake Physical examination reveals a unilateral displacement of the affected tonsil towards the midline with a bulge in the peritonsillar region and uvular deviation to the opposite side CT scan may aid in diagnosis Treatment consists of incision and drain age by experienced personnel This should be followed by a 10 - day course of oral or parenteral penicillin or clindamycin Steroids, to reduce pain and fever, may be considered as adjunctive therapy Immediate tonsillec tomy (Quinsy tonsillectomy) may be performed, but has increased hemorrhage risk A single peritonsillar abscess is a relative indication for tonsillectomy Patients with recurrent abscesses should always be considered for tonsil removal Pharyngeal injury may occur in children after falling with a pen, stick or other sharp object in the mouth Exami nation reveals a puncture or laceration of the soft palate, tonsil, or pharyngeal wall The most significant risk is a carotid injury The presence of significant bleeding, neurologic findings or a puncture lateral to the exposed tonsil should prompt immediate consultation and evaluation with angiography Adenotonsillectomy Removal of the tonsils and adenoids is one of the most commonly performed pediatric operations Recurrent tonsillitis is a common indication More than 5-6 episodes of tonsillitis in a year or significant missed time from school or work should prompt consideration for tonsillectomy Other indications include obstructive sleep apnea, suspicion of malignancy and previous peritonsillar abscess Surgery is performed on an outpatient basis in older children The most significant risk of tonsillectomy is postoperative hemorrhage Obstructive Sleep Apnea f"lg 13.6: Acute staphylococcal pseudomembranous tonsillitis with unilateral hypertrophy of the right tonsil This condition has to be differentiated from other causes of white patch on the tonsil (Courtesy: Textbook of ENT, Hazarika) Obstructive sleep apnea (OSA) is characterized by episodic obstruction of airflow through the upper airway during sleep Adenotonsillar hypertrophy is the most common cause for pediatric OSA Congenital nasal masses may be responsible for neonatal OSA Physiologic sequelae may include hypoxemia, hypercapnia and acidosis The most severely affected patients may develop failure to thrive, right ventricular hypertrophy, pulmonary hypertension and cor pulmonale Patients with OSA present with noisy breathing, specifically stertor (sonorous upper airway breathing) Other symptoms include snoring, breath holding, or gasping during sleep, as well as enuresis Daytime manifestations include morning headache, halitosis and behavioral disorders Physical examination often reveals audible breathing with open mouth posture, hyponasal speech and tonsillar hyperplasia Polysomnography (sleep study) remains the gold standard for diagnosis Adenotonsillectomy is considered first-line therapy in pediatric OSA If the apnea hypopnea index is greater than _ s E_s_s_e_n_t i_ a_i_P _e_d_ i_at_r_ic_ ten then the child should be monitored closely in the postoperative period with pulse oximetery Surgical removal of nasal masses may be required In the most severe cases of OSA, tracheostomy may be considered DISEASES OF THE LARYNX AND TRACHEA Stridor The term strider refers to excessively noisy, musical breathing and is generally due to upper airway obstruc tion The relationship of strider to the respiratory cycle often provides a clue to its etiology: Inspiratory stridor suggests obstruction above the vocal cords (supraglottis), while expiratory stridor usually originates from the distal trachea (Table 13.4) Biphasic (inspiratory and expiratory) strider usually originates from a subglottic or proximal tracheal lesion Most pediatric strider originates from supraglottic lesions Table 13.4: Supraglottic compared to tracheal obstruction Supraglottic obstruction Tracheal obstruction Inspiratory stridor Weak cry or voice Dyspnea is generally mild Less pronounced cough Biphasic or expiratory stridor Normal cry or voice May have severe dyspnea Deep barking, brassy cough Evaluation of the stridorous child should include a thorough history Physical findings include nasal flaring and suprasternal or intercostal retractions Chest X-rays or lateral neck films may confirm diagnoses such as retropharyngeal abscess, epiglottitis, or croup Barium esophagram or CT may rule out extrinsic vascular compression Flexible and rigid endoscopy is generally needed to confirm the diagnosis There are multiple causes of pediatric airway obstruction, some of which are listed below Infections Croup (laryngotracheobronchitis) is a viral upper respiratory tract infection and often presents in children 1-5 yr of age with biphasic strider, barking cough and low-grade fever Onset of symptoms is usually over several days Chest X ray reveals a characteristic narrowing of the subglottic region known as the steeple sign (Fig 13.7) Most cases of croup are mild and resolve within to days Conservative management should include reassurance, cool mist and oral hydration Children with strider at rest should be hospitalized for close observation, cool mist and supplemental oxygen Therapy with epinephrine (1:1000 in doses of 0.1-0.5 ml/kg to a maximum dose of ml), gives through a nebulizer helps in relief of symptoms A single dose of dexamethasone (0.3-0.6 mg/kg IM) reduces overall severity during first 24 hr Recently, inhalation of budesonide in doses of mg twice a day for days has shown satisfactory results Fig 13 7: Laryngotracheobronchitis (croup) 'Steeple sign' Antibiotics are indicated only if the child fails to improve or if purulent secretions are present Coverage should be directed towards Staphylococcus and H influenzae Acute epiglottitis (often called supraglottitis), although less common than croup, typically presents with a greater degree of airway compromise Patients typically present with acute onset (over several hours) of sore throat, marked dysphagia and high fever Patients are often encountered leaning forward in a 'tripod' position, toxic appearing and drooling Unlike croup, cough is frequently absent Lateral neck X-ray reveals a characteristic thickening of the epiglottis ('thumbprint' sign) or other supraglottic structures H influenzae type B is the major etiologic organism If epiglottitis is suspected, rapid airway management is essential and includes intubation by skilled personnel Instrumentation of the throat with tongue depressors is not advised as this can precipitate a fatal laryngospasm Management includes securing the airway and broad spectrum IV antibiotics, e.g coamoxiclav, ceftriaxone or cefuroxime The incidence of epiglottitis has declined since the use of vaccines against H influenzae Bacterial tracheitis is typically seen in younger children following viral upper respiratory tract infection The child appears toxic with a brassy cough and strider Patients have a classic irregular tracheal wall on X-ray Bronchos copy is both diagnostic and therapeutic, as the purulent tracheal secretions can be visualised, cultured and mechanically debrided Bacterial tracheitis is a relative medical emergency, as life-threatening obstruction may develop from these tracheal secretions The responsible pathogen is usually S aureus Retropharyngeal abscess is a potential suppurative complication of bacterial pharyngitis that may present with strider Patients often have high fever, reduced mobility of the neck and appear toxic Complications of Rights of Children Rajeev Seth The Constitution of India guarantees equality before the law to all citizens and pledges special protection for children In 1992, India accepted the obligations of the UN Convention on the Rights of the Child (CRC) In the last two decades, the government has taken several steps towards publicly advancing children's rights These include the formation of the National Commission for Protection of Child Rights (2005), a National Plan of Action for Children (2005) and advancing various legislations such as Right to Education (2009) to protect, promote and defend child rights in the country Physicians need to be familiar with child rights in order to ensure advocacy for children and their families Table 31.1: Articles of the UN Convention on the Rights of the Child that apply to child health Article Article Article Article Article Article United Nations Convention on the Rights of the Child The United Nations Convention on the Rights of the Child (UN CRC) is the first legally binding international instru ment to incorporate civil, cultural, economic, political and social rights for children It sets out these rights in 54 articles and two optional protocols Table 31.1 provides articles of UN CRC that apply to child health There is sufficient evidence globally to acknowledge that the UN CRC has influenced childrens access to health and well-being Every pediatrician can, and should have, adequate knowledge of the rights of children in domains of child survival, identity, development, protection and parti cipation They should understand the broad social deter minants of child health, become trained in the use of CRC, align themselves with like-mindedorganizations in efforts at advocacy, and lobby their local, state and national elected representatives to advance child rights Promotion and Protection of Child Rights in India In 2006, the Government of India upgraded to an independent status the Ministry of Women and Child Development, in order to focus on issues concerning the welfare of women and children The National Commission 768 Article 12 Article 14 Article 16 Article 17 Article 18 Article 19 Article 20 Article 22 Article 23 Article 24 Article 27 Article 28 Article 30 Article 31 Article 34 Purpose Protection from discrimination Best interests of the child are a primary consi deration: The institutions, services and facilities responsible for the care or protection of children shall conform to the standards established by competent authorities Parents are responsible for ensuring that child rights are protected Right to survival and development Right of the child who is separated from one or both parents to maintain personal relations and direct contact with both parents on a regular basis Right of a child to express his/her views, consi dering the maturity of the child Freedom of expression including seeking, receiving and imparting information Protection of privacy Access to information from mass media, with protection from material injurious to the child's well-being Assistance to parents with child rearing responsi bilities Protection from physical and mental violence, abuse or neglect Special protection to children deprived of their families Protection of children seeking refugee status Rights of disabled children to special care Right to health and access to health care Right to an adequate standard of living Right to education Right to the child's own culture and religion Participation in leisure and play Protection from sexual exploitation _ _� _ h_ _il _d_ren R-ig_ ht_ s_o_tc or Protection of Child Rights, constituted in 2007, provides 'or setting up of state level Commissions meant for protection and promotion of child rights in the country Besides the institutional, administrative and legislative framework, India has a strong presence of non-Governmental organizations (NGOs) that, along with the media, act as watchdogs to protect human and child rights Measures for Implementation Several policies, laws and programs have been introduced to implement the national commitment to child rights These include: National Policy for Children (1974) This policy declared children as being a supreme national asset National Charter for Children (2003) The charter emphasizes the Government's commitment to rights of children, while enumerating children's duties towards their families, society and nation National Plan of Action for Children (2005) This plan commits to ensuring rights of all children by creating an enabling environment for their survival, growth, development and protection National Policy for Persons with Disabilities (2006) The policy recognizes that a majority of persons with disabilities can lead a better quality of life if they have access to equal opportunities and effective rehabilitation measures Policy Framework for Children with AIDS in India (2007) This policy seeks to address the needs of children affected by HIV /AIDS, by integrating services for them within the existing development and poverty reduction programs National Rehabilitation and Resettlement Policy (2007) Under this policy, no project involving displacement of families can be undertaken without a detailed assessment of social impact on the lives of children National Urban Housing and Habitat Policy (2007) The policy seeks to promote sustainable development of habitat and services at affordable prices in the country and thereby provide shelter to children from disadvantaged families National Legislation The legislative framework for children's rights is being strengthened by the formulations of new laws and amendments in old laws These include the Food Security bill (2011), Right to Free and Compulsory Education Act (2009), Prohibition of Child Marriage Act (2006), the Commissions for Protection of Child Rights Act (2005), Amendments to Juvenile Justice (Care and Protection of Children) Act (2006), Right to Information (2005), the Goa Children (amendment) Act {2005), the Child Labor (Prohibition and Regulation) Act (1986) and Information and Technology (amendment) Act {2008) Two noti fications in 2006 and 2008 expanded the list of banned and hazardous processes and occupations New legislations include the Bill for Prevention of Offences against the Child and the HIV/AIDS bill National Programs The Government of India is implementing several pro grams on social inclusion, gender sensitivity, child rights, participation and protection These programs include: Integrated Child Development Services (ICDS), Kishori Shakti Yojana and Nutrition Program for Adolescent Girls, Rajiv Gandhi Creche Scheme for children of working mothers, Sislzu Grah (scheme for assistance to homes for children to promote in-country adoption), Dhanalakshmi (conditional cash transfer schemes for the girl child), Program for Juvenile Justice, Child Line (outreach services for children in need of care and protection through 24 hr toll free number 1098), Integrated Child Protection Scheme, Integrated Program for Street Children, Ujjawala (scheme for prevention of trafficking and rescue, rehabilitation, reintegration and repatriation), Sarva Shiksha Abhiyan (scheme to address educational needs of to 14-yr-old and bridge social, gender and regional gaps with active community participation), National Program for Edu cation of Girls at elementary level (Kasturba Gandhi Balika Vidyalaya), National Rural Health Mission, Mid-day Meal Program, Jawaharlal Nehru National Urban Renewal Mission, Universal Immunization Program (UIP) and Integrated Management of Neonatal and Childhood Illness (IMNCI) Role of Pediatricians in Realizing Child Rig hts The most basic and crucial child rights are survival and early childhood care, including health care, nutrition, growth, development and education Prevention of neglect and protection from exploitation (street children, child labor, trafficking) are complex issues Parents are often illiterate and ignorant of the rights of their children; awareness of these rights is essential so that they can fight to obtain them Pediatricians should join hands with committed groups of multidisciplinary child health professionals, nurses, teachers, social workers, psychologist, lawyers, police, judiciary, child rights activists and community leaders in order to work together and monitor governmental efforts in promotion and protection of various child rights They should be able to gather and collate available indicators of national child health, address key issues and concerns and facilitate children's participation in projects and policy development Pediatricians should collaborate with national and international NGOs to initiate advocacy campaigns and media releases in order to change policy, legislations and practice in accordance with the UN CRC CHILD ABUSE AND NEGLECT The term child abuse has different connotations in different cultural milieu and socioeconomic situations The World Health Organization (WHO) defines child abuse or - s -E.s s.e.n ti.a _1 _P_e_d_ia_t_r1.c _ maltreatment as forms of physical and/ or emotional ill treatment, sexual abuse, neglect or negligent treatment or commercial exploitation that results in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power Major types of child abuse by caregiver or other adults include: Physical abuse Acts of commission by a caregiver that cause actual physical harm or have the potential for harm Sexual abuse Those acts where a caregiver uses a child for sexual gratification Emotional abuse The failure of a caregiver to provide an appropriate and supportive environment, including acts that have an adverse effect on the emotional health and development of children Neglect The failure of a parent or guardian to provide for the development of the child, where he/ she is in a position to so, in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions Neglect is thus distinguished from circumstances of poverty, in that neglect can occur only in cases where reasonable resources are available to the caregiver Manifestations Injuries inflicted by a caregiver on a child can take many forms Patterns of injury to the skin are noted Skeletal manifestations of abuse include multiple fractures at different stages of healing Death in abused children is most often the consequence of a head injury or injury to internal organs About one-third of severely shaken infants die and the majority of survivors suffer from longterm consequen ces such as mental retardation, cerebral palsy or blindness Children who have been sexually abused may exhibit symptoms of infection, genital injury, abdominal pain, constipation, chronic or recurrent urinary tract infections or behavioral problems Many children will disclose abuse to caregivers or others spontaneously, although there may be additional direct physical or behavioral signs Emotional and psychological abuse has received less attention globally due to cultural variations in different countries Corporal punishment of children, in the form of slapping, punching, kicking or beating, is a concern in schools and other institutions Child neglect can manifest as failure to thrive, failure to seek basic health care, immunization and depri vation of education and basic nutrition needs A neglected child is exposed to environmental hazards, substance abuse, inadequate supervision, poor hygiene and abandonment Strategies to Reduce Child Abuse and Neglect Preventing child abuse and neglect should be part of national agenda In India, abuse and neglect of children is a major social and public health problem, especially among socially marginalized and economically backward groups, such as children in urban slums, street and work children and children of construction workers While cl labor cannot be abolished in the presence of abject pove; the Government should ensure that working children, not exploited Protection of children against all forms abuse and exploitation is a basic child right The emplo) must provide for health care for children and ensure th they get time for education A comprehensive approach to child protection services rural areas should involve the established system c Panchayati Raj The panchayat officials should be responsibl for ensuring basic education, nutrition, health care am sanitation for every child in the village It should be bindinf on the panchayat to ensure that each child attends school anci is protected from agrarian and allied rural occupations as a part of family or individual child labor Pediatricians have a significant role in recognizing, responding to and reporting child abuse They are often the first point of contact of a child with abuse and the best advocates for protection of their rights While Indian laws not make it mandatory to report child abuse and neglect, pediatricians should seek assistance from Special Juvenile Police units, Child Welfare Committees, Child Line (an emergency toll-free phone service for children in distress), National and state Commissions for Protection of Child Rights (NCPCR) and NGOs, and direct families to these services Pediatricians can work with the community, NGOs and governmental administrators to reach out to neglected, deprived and abused children Suggested Reading Aggarwal K, Dalwai S, GaJagali P, Mishra D, Prasad C, Thadhani A, et al Recommendations on recognition and response to child abuse and neglect in the Indian setting Jndian Pediatr 2010;47:49�504 Convention on the Rights of the Child, available from www.unicef org/crc Delhj Declaration http: www.inruanpediatrics.net/delhi declaration 2011.pdf Srivastava RN Child abuse and neglect: Asia Pacific Conference and the Delhi Declaration Jndian Pediatrics 2011;49:ll-2 Study on Child Abuse: India (2007) Ministry of Women and Child Development, Government of Jndia, available from www.wcd.nic.in/ childabuse.pdf Thjrd and Fourth combined periodic report on the Convention on the Rights of the Child 2011, available from www.wcd.nic.in ADOPTION Adoption is an important option for the rehabilitation of destitute and abandoned children or those who cannot be brought up by their parents due to social reasons Medical practitioners play a vital role in influencing health and social decisions of their adoptive patients and should work closely with counselors and health professionals Legal Aspects 'Right to a family' is proposed as a fundamental right by the United Nations Adoption agencies should ensure that these rights are protected In India, only agencies recognized by n i i f _ _ h _ _ ld_r_e _ h _ t_ s_oc R- g the Government can deal with adoption placement Private adoptions, including direct placement by hospitals, maternity and nursing homes, are illegal Prior to 2000, adoption was allowed to Hindus under the Hindu Adoption and Maintenance Act; other religious groups were governed by the Guardianship and Wards Act The Juvenile Justice (Care and Protection of Children) Act, passed by the parliament in 2000, enables citizens of all religions the freedom to adopt a minor child, irrespective whether he/she is a single parent Such adoptive parents may adopt a child of the same sex, irrespective of the number of living biological sons or daughters Procedure of Adoption A child, who has been relinquished by his/her biological parents or found abandoned, must first be presented to the Child Welfare Committee Under the current law, this committee has the sole authority to declare the child available for adoption After due investigations, the committee declares the child as destitute and available for adoption In case the biological parents want to relinquish a child, they have to execute a document in favor of the adoption agency, witnessed by any authority of the hospital and a relative A waiting period of two months is given to biological parents to reconsider the decision, following which the child is free for adoption Prospective Adoptive Parents A child can be adopted by a married couple with infertility or those voluntarily opting for adoption Even single persons are eligible to adopt Couples who have taken a decision to adopt should go to an agency licensed by the state government and the Central Adoption Resource Authority, an autonomous body in the Ministry of Women and Child Development Only recognized placement agencies can process the application of abandoned Indian children for in-country and inter-country adoptions Applications for inter-country adoption of a child born in India should be forwarded by an accredited agency of the country of the adoptive parents, to an agency in India, along with all documents to the Central Adoption Resource Authority A social worker from the adoption agency performs pre adoption counseling, which includes providing guidelines and support to pre-adoptive parents, helping them make informed decisions A home study is conducted by a pro fessional social worker Additionally, parents are required to submit a document regarding their health and financial status Once the application is approved, a suitable child is shown to them After they accept the child, placement is legalized The placement is followed up to a period of yr or such time until legal adoption is complete The adoptive parents are assured confidentiality and provided support as needed Role of the Pediatrician Families often take pediatricians into confidence and seek their advice Additionally, babies in placement agencies are usually taken for a second opinion to a pediatrician Pedia tricians can counsel and teach families about the process of adoption A supporting and understanding attitude encourages adoptive parents to overcome their fears The physician should examine the child carefully and explain to the adoptive parents the diagnoses, if any, and their prognosis They should ensure that all essential tests (such as HIV, hepatitis B) with a window period are repeated at and months before placement Parents who wish to relinquish their children due to any reason should be counseled about the correct procedure so as to ensure that children are not left in public places or unhealthy surround ings, which may be unsafe and traumatizing Suggested Reading Central Adoption Resource Agency; www.adoptionindia.nic.in Index Abdominal pain 286 chronic 289 common causes 287 red flag signs 290 related to functional gastrointestinal disorders 290 Abdominal tuberculosis 305 Accredited social health activist (ASHA) 2, Accidents 696 Acid-base disorders 83 algorithm 83 Acid-base equilibrium compensation for primary disorders 83 regulation 83, 84 renal regulation of 84 Acne vulgaris 682 Acute diarrhea assessment 292, 293 causes 291 clinical findings 291 dehydration 292 drug therapy 296 laboratory investigations 292 management 293, 295 oral rehydration solution 294 prevention 296 treatment 294, 295 zinc supplementation 295 Acute disseminated encephalomyelitis 569 Acute flaccid paralysis 592 differential diagnosis of 592 surveillance 592 Acute glomerulonephritis 474 etiology 474 indications for renal biopsy 474 Acute hemiplegia of childhood 577 causes 577 clinical features 577 management 578 Acute kidney croup injury 487 clinical features 487 complications 489 definition 487 dialysis 491 etiology 487 evaluation 487, 492 investigations 488 management 488 newborn 491 staging 487 Acute laryngotracheobronchitis, see Croup Acute liver failure, see Liver failure Acute lyrnphoblastic leukemia 599, 600 chemotherapy protocol for 603 clinical presentation 601 differential diagnosis 601 Down syndrome 601, 605 evaluation 602 management 602,603,604 prognostic factors 600 risk factors 599 treatment after relapse 604 Acute myeloid leukemia 605 classification 606 clinical features 606 genetic abnormalities 605 treatment 606 Acute promyelocytic leukemia 607 Acute otitis media 359 etiology 359 treatment 359 with effusion 360 Acute nephritic syndrome,etiology of 474 Acute renal failure,see Acute kidney injury Acute respiratory distress syndrome 393 Acute respiratory tract infection (ARI) control program 380 WHO classification 381 Acute viral hepatitis, see Hepatitis Acyanotic congenital heart defects 413 Adenotonsillectomy 367 ADHD, see Attention deficit hyperactivity disorder Adolescence 63, 65 attitude towards health 65 cognitive, social development 63 health problems 65, 66 immunization 69 legal age 67 transition to adult care 69 Adolescent adolescent friendly health services 68, 69 contraception 67, 69 Adoption 770 legal aspects 770 procedure 771 Adrenal insufficiency 523 Adrenocortical excess 523 Adrenoleukodystrophy, X-linked 664 AFP, see Acute flaccid paralysis Age independent indices 97 Aldosterone excess 525 Alkaptonuria 653 Alloirnmune thrombocytopenia, neonatal 352 Alopecia areata 683 Alport syndrome 473 Amblyopia 669 Amebiasis 268 clinical features 269 diagnosis 269 treatment 269 Amebic meningoencephalitis 271 Aminoacidopathies 652 Analgesics 739, 740 Anemia 330, 331 approach to macrocytic 333 approach to microcytic 332 approach to normocytic 333 773 clinical features 331 evaluation 331 Anganwadi worker 2, Anion gap 84 urinary 85 Anomalous left coronary artery from pulmonary artery 448 Anorectal malformation 177 Anorexia nervosa 57 Antenatal hydronephrosis 507, 508 Anterior horn cells, disorder affecting 588 Anticonvulsants 554, 745 for refractory status epilepticus 555 Antidotes 745 administration of 700, 701 Antiphospholipid antibody syndrome 629 Antitoxins 746 Aortic regurgitation 441 clinical features 442 differential diagnosis 442 management 442 Aortic stenosis 429 assessment of severity 430 clinical features 429 treatment 431 Apgar score 126 Aplastic anemia 345 congenital syndromes associated with 346 etiopathogenesis 345 laboratory studies 346 treatment 347 Apnea 125, 171 Appendicitis, acute 287 Arrhythmia 457, 458, 714 diagnosis of tachyarrhythrnia 458, 459 initial assessment 459 irregular wide QRS tachycardia 461, 462 narrow QRS tachycardia 460, 462 narrow QRS tachycardia 459, 460 treatment for bradyarrhythrnias 459 Arterial catheterization 731 Arthritis 624 approach to diagnosis 624 classification 624 reactive 624 septic 624 synovial fluid characteristics 625 tubercular 624 Ascites 318 causes 318 investigation 318, 734 treatment 318 Ascitic tap 734 Asphyxia 125, 166 diagnosis and approach 167 multiorgan dysfunction 166 neuropathology 166 post-resuscitation management 167 prognosis 168 s _ _E s s e n t, a· l P_e _d_ia_ t_ri_c_ Aspergillosis 260 Asthma, bronchial 382,389 classification of severity 387,391 clinical features 383 diagnosis 383,389 management 384,390,747 pathology 382,383 pharmacotherapy 385 step wise treatment 386,387 Asymmetric tonic neck reflex 143 Ataxia-telangiectasia 186,580,586 Ataxia 579 acute cerebellar 579 causes 579 Friedreich 580 Atopic dermatitis 680 Atrial septa! defect 413 assessment of severity 414 complications 414 physiology 413 treatment 414 Attention deficit hyperactivity disorder 59 clinical features 59 diagnosis 59 management 60 Autistic disorder 61 Autoimmune hemolytic anemia 340 clinical features 340 cold reactive autoantibodies 340 management 340 warm reactive autoantibodies 340 Autoimmune liver disease 321 Autosomal dominant disorders 641 Autosomal recessive disorders 641 Brain tumors 571,612,613 brainstem 571 cerebellar 571 clinical presentation 613 diagnosis 614 supratentorial 572 treatment 614 Breast milk benefits of 150 composition of 153 expressed 155 Breastfeeding 90, 150,151,154 drug therapy 180 physiology 151 principles 90 problems in 154 technique of 153 Breath holding spells 58 Bronchial asthma,see Asthma Bronchiectasis 392 Bronchiolitis 381 causes 382 clinical features 381 differential diagnosis 382 treatment 382 Bronchodilators 386,747 Bronchopulmonary dysplasia 171 Bronchoscopy 373 Brucellosis 259 Bruton agammaglobulinemia 186 Budd-Chiari syndrome 320 Bulimia 57 Bullous impetigo 688 Bums 705 Bacillus Calmette Guerin (BCG) 190 Bag and mask ventilation 129,712 Baggy pants appearance 99 Bangle test 97 Barlow maneuver 141 Bartter syndrome 501 Basophilia 357 BCG test 254 Becker muscular dystrophy 595 Behavioral disorders 57 Beh