1. UF Service Trips Common Clinical Issues in Children Rob Lawrence, MD Pediatric Infectious Diseases

2. Outline Objectives An Approach to Diagnosis Growth / Development / Anemia Abdominal Pain / Diarrhea / Intestinal parasites Dengue / Malaria TB

3. Approach to Diagnosis in Resource Poor Settings Ethics  treat them as you would every patient, including sensitivity to cultural issues. Emphasize history and physical diagnosis to get to the diagnosis. Differential Diagnosis  common/endemic > urgent/critical=triage > treatable. What are you set up / prepared to manage? Empiric therapy  lower threshold, need for follow-up. Follow-up within their health system + education which is culturally appropriate.

4. Growth, Development and Anemia Growth: WHO Child Growth Standards Multicentre Growth Ref. Study (MGRS) Stunting, wasting, malnutrition Development:Assessment Tools Observation Anemia:Age, WHO standards Correlation with IQ, development and association with intestinal parasites Breastfeeding: WHO Recommendations MGRS – standards, potential AHRQ report #153 -07-E007 www.ahrq.govwww.ahrq.gov Breastfeeding: More than just good nutrition. Lawrence RM Peds in Rev 2011;32;267.

13. Growth Stunting Height-for-age is less than -2 SD (below the mean) Chronic undernutrition - retards linear growth Underweight Weight-for-age is less than -2 SD (below the mean) Inadequate nutrition over a shorter period of time Linear growth maintained Head circumference growth still OK (spares the brain)

14. Growth Wasting Weight-for-height less than -2 SD (below the mean) Acute malnutrition with probable micronutrient deficiencies Increased risk of infections, diarrheal disease, death Odds ratio of mortality ~= 2x mortality risk for children > -1 SD* Severe Wasting Weight-for-height less than -3 SD (below the mean) Severe acute malnutrition Odds ratio of mortality ~= 9x mortality risk for children > -1 SD* Black RE et al. Lancet 2008, 371:243-60. Maternal and Child Undernutrition Study Group:

15. Kwashiorkor Growth Failure Wasting – muscles Edema – abdomen, scrotum, feet Hair changes Mental changes / activity Dermatosis Appetite diminished Anemia Fatty lliver

16. Principles of Treatment for Severe Malnutrition StepDays 1-2Days 3-7Weeks 2-6 1. Hypoglycemia++++- 2. Hypothermia++++- 3. Dehydration++++- 4. Electrolytes++ 5. Infection++ + 6. Micronutrients++ (no iron) ++ (with iron) 7. Cautious feeding+++++- 8. Catch-up growth--+++ 9. Sensory stimulation++ 10. Prepare – follow-up--+++ Ashworth A et al. Child Health Dialogue Issue 3 + 4, 1996 10 Steps – Guidelines for treatment of Severely Malnourished Children

17. Malnutrition Calories Protein Micronutrients Vitamin A Iron Iodine Zinc Disease Control Priorities in Developing Countries Stunting, Wasting and Micronutrient Deficiency Disorders Caulfield LE, Richard SA et al. Chapter 28

18. Micronutrient Deficiency DeficiencyConsequencesFoodsSupplementation Vitamin ANight blindness Infection - mortality Animal foods – fat Liver, milk, egg yolks Dk green leafy vegetables, oil, Carotenoids, BM = breast milk Capsules, Fortification of salt, flour, sugar, rice, butter BM + tri-vi-sol + iron IronAnemia Neurologic impairment Immune deficiency Meat, beans, Breastmilk (BM) Fortified – cereal, salt, sugar Rx - 3 months* IodineGoiter, growth delay Intellectual impairment Water, BM if it is in the H2O and mom has adequate Iodine Water, salt, oil injection, BM – supplement mother and infant ZincGrowth retardation Immune deficiency, skin disorders, cognitive function Animal flesh, oysters, shellfish, BM Flour, maize, rehydration salts, “sprinkles”, BM -OK

19. Development AGE“MILESTONES” 6 MONTHSWatches faces, objects, smiles responsively, reaches / grasps objects – both hands, turns to name / sounds, babbling, plays with fingers + hands to mouth, sits, decreased head lag 12 MONTHSSimple gestures –shake head “no”, waves bye, says “mama, dada”, pulls to stand – crawls – cruises, follows simple commands 2 YEARSSays words (50% are “understandable”), 2-4 words in a sentence, kicks a ball, walks without help, gets excited, points to things when named, follows simple instructions 3 YEARSCopies others, converses in 2-3 phrases/sentences, climbs stairs and other things, plays make-believe, shows affection without prompting, 75% of speech understandable 4 YEARSHops and stands on 1 foot for 2 seconds, prefers to play with other children rather than alone, plays cooperatively, tells stories, draws a person with 2-4 body parts, 100% of speech understandable

20. Anemia AGE, person, locationHb (hemoglobin)Hct (hematocrit) Children (0.5 – 5 years)< 11< 33 Children (5-12 years)< 11.5< 34.5 Children (12-15 years)< 12< 36 Non-pregnant women (> 15 years, sea level) < 12< 36 Non-pregnant women (> 15 years, @ altitude, e.g. Quito 7800 ft / 2800 m) < 12.3< 37 Screening: all children 1-6 years old, girls / women >12 years old Treatment: 3-5 mg elemental iron/kg/day with juice / water between meals (not with milk), 3 months – build iron stores without ongoing losses, diarrhea / blood in stool / parasites, menses, chronic undernourished due to lack of appropriate foods)

21. Abdominal Pain Diarrhea Intestinal Parasites Inter –related and overlapping  diarrhea and intestinal parasites can be the cause of pain Abdominal pain has a broader, multi-organ differential Diarrhea can be acute or chronic and has a broad etiologic differential Intestinal parasitic infections tend to be chronic with non-specific symptoms

22. Abdominal Pain Careful history and physical exam – associated symptoms Acute - look for a surgical condition Chronic – consider peptic disorders, reflux, esophagitis, gastritis, ulcers, H. pylori, parasites, recurrent abdominal pain, UTI, abdominal migraines, inflammatory bowel disease Red Flag Symptoms – weight loss, bilious emesis, intermittent diarrhea + constipation, bloody diarrhea, fever, arthritis/arthalgias, hepatosplenomegaly, dysphagia, respiratory symptoms

23. Diarrhea Acute diarrhea – watery (volume), viruses  rotavirus, adenovirus, enteroviruses, food intolerance if < 24 hours, less commonly Salmonella, E. coli, Shigella, Cryptosporidium, Giardia, Campylobacter Chronic diarrhea (>14 days) – acute + malnutrition (Zn or Vit. A), or recurrent episodes, bacteria – E.coli (EAEC, EPEC), Shigella, Salmonella, Cryptosporidium, Cyclospora, Giardia – alternating with constipation +/- abdominal pain think parasites Acute bloody diarrhea – small frequent bloody stools, pain, tenesmus – Shigella, Campylobacter, Entamoeba histolytica, +antibiotics or hospitalization consider Clostridium difficile, Diagnosis: labs only for chronic diarrhea, or persistent bloody d. Therapy: avoid antibiotics unless febrile, anti-diarrheal meds are ineffective / not advised in children, ORT, nutrition, education Keusch GT et al. Diarrh. Diseases. C 19 Dis Control Priorities in Dev Countries

24. Parasites ParasiteImportanceDiagnosisTherapy Giardia+, water sources, persistent diarrhea, FTT Copro exam of stool Empiric Albendazole 10-15mg/kg QD x 5 da Metronidazole 15-30mg/kg ÷ Q8h x 5 da Furazolidone, Nitazoxanide AmebiasisNon=-specific GI, Colitis, Ameboma, liver abscess EIA stool, EIA blood, colonoscopy Metronidazole 30-50mg/kg ÷ Q8h for 7-10 days Luminal agent - paromomycin Tapeworms (T. Solium/Saginata) Asymptomatic, anorexia, abd. pain, FTT, Neurocysticersosis Seen in stool,Praziquantal 5-10mg/kg x 1 Hookworms-N. americanus, Ancylstoma skin – dermatitis / itch, non- specific GI, Fe, nutritional def. Albendazole 400mg PO x 1 Mebendazole 100mg BID x 3 da PinwormsPerianal itching, excoriation, rash Exam, Tape test, stool, Albendazole 100mg x 1 or 400mg PO x 1 if > 2 yrs. AscarisAbd. pain, nausea, diarrhea, GI obstruction, Loeffler’s Syn. Copro examAlbendazole 200mg x 1 or 400mg PO x 1 if > 2 yrs.

25. Important Arthropod-borne Illness Malaria - 2009 Dengue - 2010 WHO Reports

26. Comparison Dengue 50-100 million infections / yr Incubation 3-14 days (4-7) Asymptomatic – initial episodes, mild febrile illness Dengue Fever –fever -> 41 o, bone, headache,hematologic abnormalities, hyponatremia Dengue Hemorrhagic Fever / Shock – biphasic fever, thrombocytopenia, ↑ Hct, low albumin + Na, DIC, acidosis, CV collapse Severe disease = prior infection(s) Mosquito protection! Dx: clinical syndrome / endemic Rx: supportive!! Serotypes: DenV1-4 Malaria Children 3-36 months, pregnancy Incubation 12-35 days Uncomplicated  fever + non- specific sxs Complicated  cerebral, hypoglycemia, acidosis, renal / liver failure, anemia, ARDS, CV collapse Recrudescence, relapse, repeat Prophylaxis Dx; clinical, Giemsa stained smears, parasite density Rx: various drugs  specific types, Plasmodium (4)– falciparum, vivax, ovale, malariae

27. Antimalarial Drugs DrugUncomplicatedComplicatedProphylaxisCostAvailable in U.S. Chlorquine++$ (< 1)+ Amodiaquine+$(-) Quinine++$$+ Quinidine+$$$ >10+ Mefloquine++$$+ Sulfadoxine- pyrimethamine +$+ Atovaquone++$$$+ Artemethr- lumefantrine +$$+ Clindamycin++$$+ Tetra – Doxycyc+++$+ Primaquine+ hypnozoites  preventrelapse$+

28. Tuberculosis Clinical TB Disease 1 o pulmonary, LN, other organs Cough, fever, weight loss, night sweats, malaise, hemoptysis Latent TB Infection[LTBI] Rarely addressed TST, CXR, No Sx BCG (Bacillus of Calmette-Guérin) Scars - deltoid Protection – meningitis, miliary TB Effect on TST – cutoffs, 15 mm Multi-drug Resistant TB = MDR-TB Poor-compliance, mutations Co-infection with HIV + TB Inadequate infrastructure / Public Health / DOT

29. Tuberculosis Dx: clinical, CXR, smears, AFB, uncommonly culture, DNA Rx:Isoniazid Rifampin (rifamycins) Pyazinamide Ethambutol 2 o line agents Directly Observed Therapy (DOT) Public Health

30. BCG Vaccination Policy A = Universal BCG vaccination B = BCG in the past, C = never gave BCG

31. BCG Scars

32. TST Reactions