Sunday, April 13, 2014

Reducing the Risk of Sudden Infant Death Syndrome - Recommendations

The AAP guidelines to reduce the risk of SIDS in individual infants are appropriate for most infants, but physicians and other health care providers might, on occasion, need to consider alternative approaches. The major components are as follows:

  •     Full-term and premature infants should be placed for sleep in the supine position. There are no adverse health outcomes from supine sleeping. Side sleeping is not recommended.

   •     It is recommended that infants sleep in the same room as their parents but in their own crib or bassinette that conforms to the safety standards of the Consumer Product Safety Commission. Placing the crib or bassinette near the mother's bed facilitates nursing and contact.

   •     Infants should be put to sleep on a firm mattress. Waterbeds, sofas, soft mattresses, or other soft surfaces should not be used.

   •     Soft materials in the infant's sleep environment—over, under, or near the infant—should be avoided. These include pillows, comforters, quilts, sheepskins, cushion-like bumper pads, and stuffed toys. Because loose bedding may be hazardous, blankets, if used, should be tucked in around the crib mattress. Sleeping clothing, such as a sleep sack, can be used in place of blankets.

   •     Avoid overheating and overbundling. The infant should be lightly clothed for sleep and the thermostat set at a comfortable temperature.

   •     Infants should have some time in the prone position (tummy time) while awake and observed. Alternating the placement of the infant's head as well as his or her orientation in the crib can also minimize the risk of head flattening from supine sleeping (positional plagiocephaly).

   •     Devices advertised to maintain sleep position, “protect” a bed-sharing infant, or reduce the risk of rebreathing are not recommended.

   •     Home respiratory, cardiac, and O2 saturation monitoring may be of value for selected infants who have extreme instability, but there is no evidence that monitoring decreases the incidence of SIDS and it is therefore not recommended for this purpose.

   •     Consider offering a pacifier at bedtime and naptime. The pacifier should be used when placing the infant down for sleep and not be reinserted once it falls out. For breast-fed infants, delay introduction of the pacifier until breast-feeding is well established.

   •     Mothers should not smoke during pregnancy and infants should not be exposed to secondhand smoke.

   •     The national Back to Sleep campaign should continue and be expanded to emphasize the multiple characteristics of a safe sleeping environment and to focus on the groups who continue to have higher rates of SIDS. Educational strategies must be tailored to each racial or ethnic group to ensure acceptance within that cultural context. Secondary care providers need to be targeted to receive these educational messages, including daycare providers, grandparents, foster parents, and babysitters. Health care professionals in intensive care and normal newborn nurseries should implement these recommendations well before anticipated discharge.

Wednesday, January 15, 2014

ACR Criteria for diagnosis of Wegener's Granulomatosis

In  1990 American College of Rheumatology  devised a Criteria for diagnosis of Wegener’s Granulomatosis (WG), now known as Granulomatosis with Polyangitis (GPA)

Picture shows clinical features-

Criteria Included

1. Nasal or oral inflammation: painless or painful oral ulcers or purulent or bloody nasal discharge

2.Abnormal chest radiograph: presence of nodules, fixed infiltrates or cavities

3.Urinary sediment: microhematuria (>  5 red blood cells per high power field) or red cell casts in urine sediment.

4.Granulmatous inflammation on biopsy: granulomatous inflammation within the wall of an artery or in the perivascular or extravascular area (artery or arteriole)

Requirements: ≥ 2 of the above 4 criteria are required for classification as GPA.  Sensitivity 88.2%, specificity 92.0%.

The American College of Rheumatology 1990 criteria for the classification of Wegener’s Granulomatosis.  

Monday, December 16, 2013

Autoantibodies commonly associated with Systemic Lupus Erythematosus (SLE)

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation and the presence of circulating autoantibodies directed against self-antigens.Read about ACR criteria for diagnosis of SLE.

The table below illustrates the antibodies associated with various risks in SLE. This is impotant table and a frequent MCQ question as well.

Anti–double-stranded DNA Correlates with disease activity, especially nephritis, in some with SLE
Anti-Smith antibody Specific for the diagnosis of SLE
Anti-ribonucleoprotein antibody
Increased risk for Raynaud phenomenon and pulmonary hypertension
High titer may suggest diagnosis of mixed connective tissue disorder
Anti-Ro antibody (anti-SSA antibody)
Anti-La antibody (anti-SSB antibody)

Associated with sicca syndrome
May suggest diagnosis of Sjogren syndrome
Increased risk of neonatal lupus in offspring (congenital heart block)
May be associated with cutaneous and pulmonary manifestations of SLE
May be associated with isolated discoid lupus
Antiphospholipid antibodies (including anticardiolipin antibodies) Increased risk for venous and arterial thrombotic events
Antihistone antibodies
Present in a majority of patients with drug-induced lupus
May be present in SLE

Monday, December 2, 2013

Tuberculosis in children- Treatment Regimen NTP

DOTS (Directly Observed Treatment, Short-course),  the World Health Organization-recommended tuberculosis control strategy follow the following regimens in treatment of tuberculosis in adult patients compared to children. Nepal Tuberculosis Protocol has been devised for use in TB treatment in Nepal.

Tuberculosis is a prevalent disease in the developing countries with severe consequences specially in children who are more likely to develop dissemination.

Treatment consits of 2 phases-

Initial Intensive Phase- Duration is generally 2 months and it achieves rapid killing of mycobacteria. Infectious patients are rendered non-infectious by 2 weeks. Majority of patients turn sputum positive to negative by 2 months of therapy. DOTS currently focuses more on Intensive phase as the drug resistance likelihood is higher at this phase when mycobateria are more.

Continuation phase- Usually 4-5 months durations. Fewer drugs are used but for a longer duration in this phase. Drugs eliminate the remaining bacilli including persister thus preventing TB repalse. If DOTS is not possible in this phase a close supervision is instituted.

Standard code of Treatment-
Each ATT drug has an abbreviation namely-
Isoniazid- H
Rifampicin- R

And two phases as described earlier.

Category 1- new sputum smear-positive PTB,sputum negative PTB and extra pulmonary TB.
Category 2 -relapse,treatment failure,treatment after default (interrupted treatment)

Severe Extra pulmonary TB- meningitis, miliary, pericarditis, peritonitis,, bilateral or extensive  pleural effusion, spinal , intestinal , genitor-urinary.
Less Severe Extrapulmonary TB-lymph node,pleural effusion (unilateral),bone (excluding spine), peripheral joint,adrenal gland

Following regimen is recommended by Nepal Tuberculosis Protocol- Click for full image

For Children combination packs have been developed as per weight wise catergory-

The regimens are modified in various Tuberculosis like TB meningitis, TB spine etc. Special scenarios require steroid at the start of therapy-
1. TB Meningitis
2.TB Pericarditis
3.TB Pleural effusion
4. Hypoadrenalism
5.TB laryngitis
6. Severe hypersensitivity reactions to ATT drugs
7.Renal tract TB
8. Massive lymphnode enlargement with compressive effect.

Steroid is given in TBM for 4 weeks then tapered, 8 weeks and tapered in TB pericarditis and 2 weeks in TB pleural effusion.

Sunday, November 10, 2013

Eliciting the Primitive Neonatal Reflexes: Video article

Neonatal reflexes are the reflexes which are present at birth and have a predictable course of appearance and disappearance. A normally developing newborn should respond to certain stimuli with these reflexes, which eventually become inhibited as the child matures.

The List of reflexes that can be elicited in normal newborn are-
  1. Moros Reflex
  2. Rooting reflex
  3. Sucking reflex
  4. Grasp reflex
  5. Babinski reflex
  6. Asymmetric tonic nect reflex- ATNR
  7. Gallant reflex
  8. Stepping reflex
  9. Landau's reflex
  10. Tonic Labyrinthine Reflex

Click on the image to view enlarged version.

After going through the table, you can now watch this video showing the commonly elicited neonatal reflexes and their significance.

Here is a helpful library on Pediatric neurology.