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

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

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.

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 # E007 Breastfeeding: More than just good nutrition. Lawrence RM Peds in Rev 2011;32;267.

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)

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: Maternal and Child Undernutrition Study Group:

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

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

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

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

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

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 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)

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

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

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

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.

Important Arthropod-borne Illness Malaria Dengue WHO Reports

Comparison Dengue 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 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

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

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

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

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

BCG Scars

TST Reactions