Case Scenarios in Pediatric and Adolescent Practice A Parthasarathy, Dhanya Dharmapalan, Alok Gupta, Anupama Borker
Page numbers followed by f refer to figure and t refer to table.
Abdomen 35
mesenteric nodes 269f
ultrasound of 490
USG 173
colics 159, 818
with periumbilical redness in meconium peritonitis 824f
causing respiratory distress in infantile neuroblastoma with liver 459f
distention secondary to Wilms tumor 457f
mass 457
pain 571, 594
Absence seizure 163
Absolute neutrophil count 22
Absorbed toxin 616
Academic skills assessment 738
English 738, 742
malayalam 738, 742
mathematics 738, 742
Acanthosis nigricans 480, 482, 837, 838
Achalasia 512
Achondroplasia 534, 535
Acidosis persists 673
Acinetobacter 25
sepsis 25
conglobata 840
vulgaris 839, 840
Acnegenic mineral oils 840
cytomegalovirus 907
from persistent 69
human immunodeficiency virus 84
methemoglobinemia 625
ACR criteria for neuropsychiatric lupus 582
acanthotic anomaly See Acral AN
AN 838
Acrodermatitis enteropathica 68
ACTH stimulation test 502
results of 500t
Activated charcoal 617
abdominal pain 826f
in infant 825
bacillary dysentery 130
infection 130
pneumonia 104109
bronchitis 237
confusional state 583
demyelinating encephalomyelitis 156
diarrhea 76, 661
disseminated encephalomyelitis 180
encephalitic syndrome 178180
in children 180
encephalopathy, causes of 182
febrile encephalopathy 136
flaccid paralysis 172, 173
follicular tonsillitis 794
gastroenteritis 625
glomerulonephritis 296
with normal complement level 303t
hemolysis 403
hemolytic anemia 578
hepatitis 274
idiopathic thrombocytopenic purpura 422
inflammatory demyelinating polyneuropathy 175
laryngotracheobronchitis 651
laryngotracheobronchitis See Viral croup
leukemia 422, 575
lymphoblastic leukemia 449, 450, 575
management of ischemic stroke 158
methemoglobinemia 625
motor axonal neuropathy 177
myeloid leukemia 451, 452
myeloid leukemia See Chloroma
nasal vestibulitis 801, 802
nephritis with low complement level 303t
externa 799, 801
media 103, 784, 785
pancreatitis 270, 271, 661
in children 272
pneumonitis with lupus erythematosis 242
postinfectious nephritis 304
distress syndrome 271, 620, 621f
infection 207
scrotum 379f
severe asthma 654
suppurative otitis media 774
tonsillitis 794
urticaria 876
encephalitis, etiology of 183t
hepatitis A 274
Adalimumab 570
Addison’s disease 511
Administering injections, different ways of 916f
Adolescence 695
disorder in 732
with intentional poisoning 646
cause 500
cortical function, investigations of 502
insufficiency 511
causes of 511
Adrenaline 658
infusion 677
Adrenocorticotropic hormone 160, 510
Adynamic obstruction 821
Aemolytic Streptococcus 795
Agenesis of cerebellar vermis See also Hypoplasia
Alacrima 512
Albuminocytologic dissociation 173
Alcoholic parent, child of 710
Alcoholics screening test, children of 710
Alert, verbal responsive, pain responsive, unresponsive See AVPU
Alexander disease 170
Alkaline phosphatase 42, 46, 296, 567, 571, 585
pleural effusion See also Asthma
rhinitis 601, 607, 610
rhinosinusitis 600, 601, 605
case of 599
with asthma 599
with atopy 609
with eczema 599
sinusitis 607
Allergy 597
Allgrove syndrome 512
areata 845, 846
diagnosis of 846
totalis 847
universalis 847
Alper’s disease 292
Alpha-glucosidase enzyme 144
Alternate prism cover test 754
Altruism See Romantic relationships
Alveolar hemorrhage 247
Ambiguous genitalia 381
American Association of Mental Retardation 735
Amiel-Tison angles 38
Amikacin 226, 545
Amlodipine See Calcium-channel blockers
Amoebic 817
Amoxicillin 99, 104, 807
clavulanate 97, 104, 106, 807
Amyloidosis 573
Anaphylaxis 681
cause of 682
preparedness 683
Anaplastic ependymoma 151f
Androgenetic alopecia 839
Anemia 62, 71, 76, 248, 393
causes of 435
correction of 411
deficiency of 441
of chronic disease 73
signs of 403
symptoms of 403
treatment of 442
Anger control 711
Angioneurotic 653
edema 652
Angiotensin-converting-enzyme 22
Animal milk protein 258
Anomalous pulmonary venous connection 207
Anorectic agent 484
bilateral hydronephrosis 370f
renal pelvis dilatation 313
bilateral hydronephrosis 370
unilateral hydronephrosis 367
angulations of shoulders 601
epistaxis 798
fontanel 29
horn cell 144, 173, 174
myocardial infarction pattern 213f
rhinoscopy 773
Anterolateral aspect of thigh for intramuscular injection in infant 915f
Anthralin 860
Anthropometry, interpretation of 471, 515
choice of 678
eyedrops 606
Anticholinergic effects 628
Antidotes 619
for poisons 619t
Antiendomycin antibodies 437
Anti-epileptic drugs 163
Antihistamines 682, 808
Antihyperglycemic agents 632
Anti-idiotypic 877
Anti-Müllerian hormone 383
Antineutrophil cytoplasm antibody 588
Antinuclear antibody positivity, significance of 569
Antiphospholipid antibodies 577
Antiplatelet dose 595
Anti-ribonucleoprotein 577
Antiscabetic medication, application of 855
Antisocial personality 715
disorder 717
Antistreptolysin o 572
Anti-thymocyte globulin 414
Anti-thyroid antibodies 517
Anti-TNF therapy 595
Anti-tuberculosis therapy 884
Anti-tumor necrosis factor-α 570
disorder with obsessive compulsive traits 742
management of 743
Aorta, coarctation of 196
Aphthous ulcers lower lip 259f
Aplasia 30
Aplastic anemia 422
Appetite, loss of 65
Aptitude tests, differential 699
after IV cannulation 917f
span, increased 546f
blood gas 14, 208, 219t, 624, 671
switch operation 212
Arthralgia 65
Arthritic presentation of childhood leukemia 574
Arthritis 91, 437
Arthritis See Right knee joint
Asbury’s diagnostic criteria for Guillain-Barré syndrome 177t
Aseptic meningitis 594
Asom, treatment of 776
Asperger syndrome 744
fumigates 791
niger 791
Asphyxia 24
Aspirated foreign body 887
Aspiration pneumonia 225
Asthma 86, 121
comorbidity of 600
history of 611
severity in emergency room, management of 655t
Astrocytoma 465
Asymmetrical septal hypertrophy 216, 217f
blackish discoloration of skin 837f
HBSAG positivity 283
Atenolol See Beta blockers
Atlanta symposium definition See Severe acute pancreatitis
asthma 610
keratoconjunctivitis 606
persistent severe asthma 601
Atrial septal defects 193, 194f, 195
characteristic findings of 194f
genitalia 512f
lymphocytes, causes of 907
Auditory brainstem response 50
Auspitz’s sign 860
Autism spectrum disorder 38, 48
Autoaugmentation See Detrusorectomy
Autoimmune polyendocrine syndromes 512
part of 511
Avoid benzodiazepines 678
AVPU 320
Axillary hair 489
Azathioprine 874
Azithromycin 104, 807, 840
Baby on operation table for cystoscopy 372f
Bacille Calmette-Guérin 84
Bacillus Calmette-Guérin vaccination 10, 883
Back pigmentation present over lips and around eyes 443f
Bact. Tracheitis 653
Bacteremic bacterial infection 116
pneumonia 109
tracheitis 653
Ballooning, symptom of 364
Balthazar-Ranson criteria for severity 664t
Bardet-Biedl syndrome 760
Barium enema 282f
Barrel chest 601
Barrett’s epithelium 279
cell nevus syndrome 853
estradiol level 490
Baseline hemogram 838
Basophilia 248
Bayley method 491
BCG scar, absence of 88
Bead in right ear 789f
Benzocaine 625
Benzodiazepines 163, 619
Beriberi See Thiamine deficiency
blockers 312
human chorionic gonadotropin 553
lactam antibiotics 104
dipropionate 364, 365
ointment 364
propionate ointment 860
Better diphencyprone 847
Bicarbonate 671
Bicuspid aortic valve 197
Biedel syndrome 481
Biguanide See Metformin
Biguanides 632
nasolacrimal duct obstruction 764f
severe ptosis 758f
diffuse infiltrates with sparing of peripheral zones with left basal hyperinflated area 230f
disease 884
hyperinflated lungs 234f
impacted wax 788
medial occipital encephalomalacia 161f
otitis media 779, 780
primary congenital glaucoma 753f, 754
retinitis pigmentosa 759f
tanner stage 3
breast development in one and half year old female child with premature thelarche 519f
4 breast development in girl caused by central precocious puberty 487f
hyperintensity 181f
lobe hyperintensity 179
tonsillar hypertrophy 783f
tonsils congested with multiple pus pointing 794f
vernal conjunctivitis 763f
vesicoureteric reflux 366f
widening of wrists in rickets 67f
Bilevel positive airway pressure 692
atresia 277
system 246
tract, ultrasound 12
Biotinidase deficiency 68, 543, 544
spectrum of 544
fever 96
viral fever 95, 97
Bite cells 413
Bitot’s spots 61, 62
in vitamin A deficiency 61f
Biventricular hypertrophy interventricular septum 142f
Blackish skin lesions 111
Bladder 378
exstrophy 387, 387f
wall tumor after chemoradiotherapy, complete resolution of 468f
Bland-Garland-White syndrome 215
Blaschko’s lines 851
Meckels’ diverticulum 817
neonate 28
per rectum 259
PR 280
Bleomycin 464
Blood 12, 572, 660
ammonia 543
culture 230
disorders 317
investigations 804
coagulation profile 798
loss 567
pressure 320
sugar 543, 846
level 492
transfusion 75, 283, 416, 436
history of 72
urea 567
nitrogen 296
Bloom syndrome 853, 854
Bluish discoloration of eyeballs 753
Bluish discoloration of eyeballs See Bilateral primary congenital glaucoma
Bluish patches on abdomen 415f
Body image problems 697
estimation of 477, 526
interpretation of 477
aspirate 422, 572
of megaloblast 394f
aspiration 920
hypocellular marrow with reduction 416f
foamy storage cell 291f
transplantation 292
mineral density 541
Bowing of
legs 5
lower limbs 4f
from Kenya presented with failure to thrive 298f
with marked pallor 440f
with pallor 407f
Bradycardia 617, 618, 647
Bradypnea 618
cell edema 124
infection to 97
magnetic resonance imaging of 557
parenchyma 151f
tumor 149, 465, 466
auditory evoked responses 36
encephalitis 173
evoked response audiometry 169
glioma 149
stroke 173
Branches from internal and external carotid system, anastomosis of 799f
Breathlessness 108
Breslow’s chart 923
British anti-lewisite 619
in cystic fibrosis 245
in ulcerative colitis 240, 241f
Bronchiolitis obliterans 231
Bronchoalveolar lavage 231
Bronchoconstriction 647
Bronchopneumonia 223, 224
with measles 227
with right pleural collection 224f
Bronchorrhea 617, 647
Bullous lesions 618, 851
Burning micturition, history of 442
Burst suppression 161f
Button battery
content of 634
in cricopharynx 634f
Calcipenia rickets See Hypocalcemia
Calcipotriol 860
Calcitriol 42
Calcium 41, 42, 296, 660
channel blocker 619
Calculus in right upper calyx 305f
Campylobacter 269
Canavan disease 167, 170, 171
Candida 877
albicans 791
infection 720
species 25
Candidal infection 69
Capillary blood glucose 671
Carbamate poisoning 648
Carbamazepine 29
Carbamazepine See also Phenobarbitone
Carbon dioxide See CO2
pressure of 656
Carbonyl iron 74
arrythmias 647
complication 400
failure 594
murmur 610
output 676
Cardiogenic shock 684
Cardiology 191
Cardiomegaly with right ventricle 208
Cardiopulmonary resuscitation 20
effects 628
system 35
Case of acanthosis nigricans 837
Catch up formula (f-100), composition of 77
Causing headache 152
Cavernous sinus 803f
thrombosis 803f
CDI, treatment of 497
Cefdinir 104
Cefixime 807
Cefotaxime amikacin 25
Cefpodoxime 104, 807
Ceftriaxone 104, 226
injection 916
Cefuroxime 807
axetil 104
Celiac disease See Chronic diarrhea
Cell mediated immunity 85
nervous system 5, 35, 188, 319, 492, 495, 578, 582, 628, 671
precocious puberty 500
oxygen saturation 675, 679
pressure 679
Cephalosporins 29
Cerebellopontine angle 152
edema, management of 674
malaria 124
venous sinus thrombosis 159, 320, 321
Cerebrospinal fluid 150, 179, 660
obliteration of 156
Ceruminolytic agents 788
Cervical adenitis 827
Cervical lymphadenopathy 452
Cervicocephalic arterial dissection 158
Cetirizine 808
CF transmembrane conductance regulator 245
Chemical pneumonitis 621f
Chemoreduction 766
infection 193
pain See Tightness of chest, symptom of
wall edema 692
Chickenpox 87
outbreak 87
being sick interfebrile 116
depression inventory 701
Development Centre grading 35
on arrival 668f
presented with pallor 434f
fever 434f
presenting with
delayed puberty 522
obesity 479
premature thelarche 518
suffering from fanconi anemia 417f
with accidental kerosene ingestion 620
with acute
encephalitis syndrome, management of 184t
nasal vestibulitis 802f
scrotum 379
with adenoid facies 792f
with antidepressant poisoning 627
with biotinidase deficiency 543f
with button battery ingestion 633
with delayed puberty, approach to 525
with dengue 687
with glucose-6-phosphate dehydrogenase deficiency 411f
with goiter 514
approach to 515
with hypoglycemia 630
with hypospadias 359
with increasing pallor 393f
with iron poisoning 640
with isoniazid poisoning 637
with left nasal bleed 797f
with methemoglobinemia 624
with osteogenesis imperfecta 541f
with pallor 409f
early childhood 396f
jaundice 409f
with paracetamol poisoning 642
with persistent progressive anemia 432f
with polydipsia 491
with polyuria 491
with scleral icterus 275f
with short stature 471
with status epilepticus 660t
with suspicion of Cushing syndrome, investigations in 484
with unknown drug ingestion 615
Childhood 474
absence epilepsy 164
Children with
adrenal crisis 509
risk factors for metabolic syndrome, management of 485
Childs’ abdomen with fingers 827
Chloride 296
Chloroma 450
Chloroquine 431, 625
Choanal atresia, diagnosis of 20
Cholecalciferol 67
Cholestasis 12
Chordee See Ventral penile curvature
Choreoathetotic CP, differential diagnosis of 148
Chorionic villi sampling 542, 553
Chromosomal microarray 558
functional 265
pain 265
in school-going child 827
site 266
adenoiditis 792
adenotonsillitis 783, 784
anemia 436, 474
bullous dermatosis of childhood 873
constipation 282
cough secondary to allergic rhinosinusitis 600
diarrhea 64, 68, 69, 254, 255
disease, common 81
HBEAG negative hepatitis 285
HBV infection 284
health evaluation II 663
illnesses 739
renal failure 440, 441
manifestations of 441
suppurative otitis media 776
systemic diseases 474
Cisplatin 464
Citrobacter 25
Clarithromycin 104, 807, 843
Classic dengue fever 100
Classical Hodgkin’s lymphoma 454
Clindamycin 807, 840
Clobazam 163
Clofazimine 843
Clonazepam 163
CO2 545
Coarctation of aorta, diagnosis of 197
Cockayne syndrome 853, 854
Coin in
retrieval 262f
stomach 262f
upper esophagus 830f
Colchicine 874
Cold 99, 894
history of 449
peripheries 615
Colonic mucosa eosinophilic collections 258f
nodularity and ulcerations 288f
pedunculated polyp 280f
Combined pituitary hormone deficiency 474
Communication disorder 744
Community-acquired methicillin-resistant Staphylococcus aureus 669, 669t
infection 667
Complete blood count 96, 265, 457, 467, 655, 901
revealed HB 449
Complete heart block 217
Complex partial seizure, EEG of 166f
Concerned bowing of lower limbs 4
Conduct disorder 55
adrenal hyperplasia 15, 16, 383, 501
diagnosis of 15
cataract 767, 769
glaucoma 753, 754, 765
heart disease 40, 196, 552
hypothyroidism 504
cause for 30
investigating proven cases of 508
with approach to newborn thyroid screening 503
ichthyosiform erythroderma 870
Ladd’s bands to recurrent upper intestinal obstruction and abdominal pain 828f
nasolacrimal duct obstruction 764
ptosis 757
zonular cataract 768f
cardiac failure 63
heart failure 73, 207
appear muddy 61
edema of 607
Conjunctival congestion 765
Consciousness, altered level of 615
Continuous positive airway pressure 623, 656
Contrast esophagography in case of H-type tracheoesophageal fistula 832f
Contrast lower gastrointestinal 817
Controlled diabetes mellitus 524
Coomb’s-positive hemolytic anemia 576
Coombs test 426, 441
Co-oximetry analysis of blood 625
ulceration 62
xerosis 62
Cornelia de Lange syndrome 148
Cortical thumb 5, 5f
Corticosteroids 860
Coudability sign 846
Cough 99, 894
history of 449
syrup, treatment with 237
Coumarin 29
Cow’s milk 279
protein allergy 256258
Coxsackie 269
CP mimic 145
Cranial nerve 35
palsies 45
C-reactive protein 259, 567, 662
Creatine phosphokinase 287
Creatinine 296
phosphokinase 174
Cricopharynx 262
Critical coronary artery disease 159
Crohn’s disease 259
Curdy white deposits in EAC 790f
Cushing syndrome 474, 481, 485, 578
imaging for 484
manifestation 65
tuberculosis 868
Cyanosis 618
Cyanotic congenital heart disease 209
Cyclophosphamide 583
pulse therapy 581
Cyclosporine 247, 415, 586
Cystic fibrosis 245
Cystic fibrosis See also Immune deficiency
Cystine deposits in cornea confirming cystinosis 300f
Cytokeratin 460
Cytomegalovirus 135
infection 438f, 439
Cytopenia 576
malformation 186, 189
syndrome 186
management of 189
Dapsone 625, 843
Daycare surgery 360
de Sanctis-Cacchione syndrome 854
Deafness syndrome 495
Deep brain stimulation 148
Deep tendon reflexes 35, 171
Degranulated mast cells 606
fever 903
in neonate 15
Dehydroepiandrosterone sulfate 500
Deiodinase deficiency 505
Demonstrating large head 168f
Dengue 96
chart 688
fever 904, 905
hemorrhagic fever 101
with shock syndrome 100
illness, course of 687f
monitoring chart 689f
shock 684
syndrome 96, 97, 100
expanded 99
without warning signs 688
Denver developmental screening test 35
Deoxyribonucleic acid 284, 548, 853
Depression 745
Depressive symptoms 746
Depsone 619
Dermatitis artefacta 848, 849
types of 849
Dermatology 835
Desferroxamine-iron complex, excretion of 640
Detrusorectomy 386
Developmental delay 558
Deviation of angle of mouth to right 149f
Dextraposed transposition of great arteries 199, 211f
echocardiography of 211f
Dextrotransposition of great arteries 210
leading to depression 726
mellitus 301, 479, 495, 688, 725
treatment of 630
with complex psychosocial issues 724
with poor growth 727f
Diabetic ketoacidosis 670
Diagnosis of alopecia areata 846
Diaphoresis 681
Diarrhea 114, 594, 617, 647, 681
Diarrhea See Abdominal pain
history of 442, 449
Diazoxide 632
Didmoad syndrome 495
Dietary management 76
Diethylenetriamine penta-acetic acid 314
interstitial fibrosis 247
intravascular coagulation 271
patches of pneumonia 223f
tree-in-bud appearance with areas of hyperinflation and air trapping 232f
Digoxin 619
Dilated cardiomyopathy, cause of 213
Dimercaptosuccinic acid 310, 365, 894
Dine’s formula 7
Dinitrochlorobenzene 847
cylinder 758
sphere 760
Diphtheria-tetanus-pertussis, doses of 84
Direct coombs test 9
Discolored urine See also Dysuria
Alper’s 292
course of 842
Crohn’s 259
modifying antirheumatic drugs 570
Wilson’s 272
Disseminated tuberculosis 125
Distended abdomen with fullness above umbilicus 270f
Dobutamine 676, 677
Dopamine 677
Double outlet right ventricle 209
sign of duodenal atresia 821f
with gas filled distal bowel loops 825f
Down’s syndrome 474, 549
Doxycycline 840
Dravet syndrome 162
Drowsiness 628
Drug 220
antituberculous therapy 122
errors resulting in paracetamol overdose, common types of 646
experimentation 714
in ENT infections, commonly used 807
reaction 907
DTAP vaccine 88
Duchenne muscular dystrophy 144
Dull periumbilical pain 268
Duodenal mucosa 255f
Duodenojejunal junction 14
Dust mites 601
Dyselectrolytemia 661
Dyshormonogenesis 505, 516
Dysmorphic facies 417
Dysmorphism 160
Dyspnea 625
Dystrophic soft tissue 587
Dysuria 296, 304
history of 379
symptom of 364
Ear 554, 773
boring 283
discharge, history of 449
nose and throat See also ENT
Eat chapattis 703
Ebstein anomaly 201
Ecchymosis presentation of acute leukemia 449f
patches on
abdomen 424f
back 424f
chest 424f
Ebstein anatomy 203f
subpulmonic VSD 204f
kidney 895
thyroid tissue 30
Eczema 851
Edematous bulky pancreas with areas of hypodensities 663f
Edematous EAC 800f
Effluxing urine 387
Effortless tachypnea 671
Ehlers-Danlos syndromes 548
Eisenmenger syndrome 215
Ejection systolic murmur 39
Electroencephalogram 660
Electrolytes 673
Embryonal rhabdomyosarcoma, diagnosis of 467
assessment by pediatric advanced life support (pals) guideline 651
conditions 232
room management 637, 640, 646
Emesis 617
Encephalitis 159
Encephalitis See also Brain, infection to
investigations for 183
Endocarditis 91
Endoscopic variceal ligation 264f
esophagitis 279f
scalloped duodenal mucosa 256f
Endothrix infection 867
ENT 653
fever 116, 117, 912
infection 269
Enterobacter 25
Enterocystoplasty 386
Enterohepatic circulation 9
Enthesitis-related arthritis 568, 573, 574
Enzyme level estimation 144
Enzyme replacement therapy 143
grading of 152
management of 152
Ephelides 853
Epicanthic fold 551f
Epidermolysis bullosa 873
simplex 878
Epileptic spasms 162
Epistaxis 797
Epithelial membrane antigen 460
Epstein-Barr virus 135, 174, 248, 269, 594
infections 102
Erythema 681
nodosum leprosum 843
lesions 863f
skin lesions 876f
Erythrocyte sedimentation rate 22, 174, 567
Erythromycin 104, 840
Escherichia coli 554
infection 894
atresia with tracheoesophageal fistula 820f
varices 264f
Esophagogastric junction 262
Esophagography of achalasia cardia 833f
Essential fatty acid deficiency 875
Estimated glomerular filtration rate 297
Ethmoidal polyps 774
Ethyl cysteine 369
Ethylenediaminetetraacetic acid 619
Etoposide 464
Eular/printo/pres classification 591
Evanescent skin lesions 876f
Evans’ syndrome 578
Examine eyes 37
Extended oligoarthritis 568
Extensive choreoathetotic movement of limbs 145
membrane oxygenation 200, 668
shock wave lithotripsy 306, 376
Extrahepatic biliary atresia 45, 276
Extrapulmonary tuberculosis, diagnosis of 126
examination 515
problems 553
Eyelashes in both eyes 765
Eyes, puffiness of 295
Facies 141f
Falciparum malaria 128, 129, 431
Familial adenomatous polyposis 281
centered care, role of 749
importance of 748
role of 748, 749
anemia 415417
diagnosis of 419
syndrome 299, 300
Fatigue 625
Felty’s syndrome 570
cause common to 525
presented with pallor 401f
presenting with precocious puberty 486
with Rett syndrome 559f
with precocious breast development, approach to 521
Femora anteroposterior 537f
Ferric salt 74
Ferrous salt 74
Fetal urology, society for 368
Fetomaternal hemorrhage 420, 421, 431
Fever 618
history of 379, 426f
Fibrillation potential 174
Fibrillin gene, analysis for 548
Figure-of-eight appearance 208f
Fine needle aspiration cytology 453
First-line antibiotics 807
Fixed drug eruption 850, 851
Flair hyperintensity of acute infarct right basal ganglia and internal capsule 155f
Flash chronic follicular tonsillitis 677
Flat facies with upslant 551f
Fleshy mass in left nasal cavity 804f
Flexible fiberoptic bronchoscopy 653
levels mainly restricted to upper abdomen in jejunal atresia 823f
management in dengue with shock 689t
management 692
with respiratory distress 692
therapy 672
in severe dengue with compensated shock 686
Fluorescent in situ hybridization 558
Fluticasone plus salmeterol 607
mucosal edema 774
segmental glomerulosclerosis 296
Folic acid 397
supplementation 408
Follicle stimulating hormone 487, 524, 723
Follicular conjunctivitis 763
Folliculitis, evidence of 839
Food allergy 269, 608
Food, types of 722
Forced vital capacity 605
Foreign body
airway 652, 653
aspiration 234
bronchus 795, 796
ear 789
esophagus 781
git 261
in right ear 789f
in stomach 261f
ingestion 829
in child 829
nasal cavity 777
diarrhea 253
syndrome 8
Fourth ventricle ependymoma without hydrocephalous 466f
Fractional excretion of sodium 323
Fragile X syndrome 558f
Framework to approach child with status epilepticus 659
Freckles See also Ephelides
Full-term normal delivery 736, 837
Fundocervical ratio 488
Fundus examination cherry red spot 292f
hyphae 26f
infections 26
sepsis 26
Fungus 601
G6PD deficiency 411, 412
G6PD deficiency See glucose-6-phosphate dehydrogenase deficiency
Gabapentin 177
Gain height and weight, failure to 418f
Galactose-1-phosphate uridyltransferase enzyme 556
Galactosemia 554, 556
Gallstones 267, 267f
Galt enzyme 556
Ganciclovir 439
Gardner’s syndrome 281
Gas chromatography mass spectrometry 558
aspirate 637
fluid, discoloration of 637
lavage 123, 617
Gastroenterology 251
Gastroesophageal reflux 611
disease 15, 162, 171, 278
decontamination 629
malformations 553
tract 36
obstruction of 820
Gaucher’s disease 292
Genetic 529
counseling 36, 162, 549, 553, 563
tests 526
Geneticist for DD/ID-A cost effective strategy 558
examination 471, 522
hair development 499f
Genitals, examination of 486
valgum 67
varum See Lower limb, deformities of
Germ cell tumors 456, 463, 464
Gestational diabetes mellitus, history of 479
GH deficiency, tests for 477
Ghost cells 413
GHST, results of 473f
Giant cells 278
Girl with
massive hepatomegaly 286f
persistently raised serum creatinine 295f
puffiness of eyes 295f
Glasgow coma scale 671
Glass appearance in case of peritonitis with secondary obstruction and fluid levels 824f
Glomerular basement membrane 245
Glucocorticoids 569, 579
normal saline 671
rate calculator 19f
tolerance test 534
Glue ear 780
Gluteal crease short 384f
Glycated hemoglobin 534
Glycogen storage disease 285, 287
agonist stimulation test, results of 520t
of tests, results of 487t
test 520
Goiter, examination of 515
Goldenhar syndromes 51
Goldmann perimetry 760
Gonadotropin releasing hormone 526
agonist stimulation test 520
Goodpasture’s syndrome 244, 303
Gottron’s papules 584, 586
Gram’s stain 666
Granulation in EAC 800f
Grave’s disease 515
Grayish black mass in right nasal cavity 777f
Griseofulvin 868
Groin swelling 811
cardiomegaly 202f
pericardial effusion 206f
chart of index case 476f
charts, role of 6
failure 723
deficiency 472f
levels 563
stimulation test 472, 478
treatment 533
of xeroderma pigmentosum 852f
Guillain-Barré syndrome 171, 173, 175, 275, 582
Gynecomastia, causes of 719
H influenza 411
Haemophilus influenza 406, 776, 786, 795, 905
Hair abnormality 544
Hallmark of psychotic depression in older children 746
Hallucinations, presence of 746
Hammered brass 847
Hansen’s disease 841, 842, 865
methemoglobinemia 624
Hapatitis B vaccines during infancy, doses of 86
Harrison’s sulcus in lower ribs 67
Hartnup disease 853, 854
encephalopathy 182
thyroiditis 515
HAV infection 275
HDL cholesterol 483
Head circumference 7, 479
Headache 625, 894
assessment 37
defects 553
Heart border, clearing of 604f
Heinz bodies 413
Hemangioma 32
swelling on upper eyelid 31, 31f
Hematocrit 689, 901
Hematology 391
Hematopoietic stem cell 419
transplantation 403
Hematuria 301
Hematuria See Kidney
Hemodialysis for chronic renal disease 86
Hemoglobin 11, 65, 72, 76, 255, 273, 282, 296, 567, 679
Hemogram 38, 795, 846
anemia 273, 399, 421
absence of 576
facies 399
facies See also Lymphadenopathy
uremic syndrome 225, 318, 425, 427, 428, 429
Hemophagocytic syndrome 248
Hemophilus influenzae type B 84
disease of newborn, types of 425
gingivitis 65
pulmonary edema 622
Henoch-Schönlein purpura 303, 318, 319, 587, 588, 589
Hepatitis 437
A 275
vaccine 87
doses 86
immunoglobulin 85, 285
virus 86, 284
Hepatobiliary iminodiacetic acid 276
scan 46
carcinoma 284
necrosis 278
Hepatosplenomegaly with
ascites 273f
developmental delay 291f
Hereditary spherocytosis 406, 409
diagnosis of 408
encephalitis 178, 179, 181f, 183
infection 438f
viral encephalitis 134
virus 135, 179, 248
zoster ophthalmicus 843, 844
HGPRT enzyme See Hypoxanthine-guanine phosphoribosyltransferase enzyme
HIB vaccination 89
HIDA scan See also Hepatobiliary iminodiacetic acid
myopia, spectacles for 546f
performance liquid chromatography 399
uric acid 375
Hip examination 35
Hirschberg’s test 766
Hirschsprung’s disease 283, 822, 891, 892f
Hirsutism 839
Histamine receptors, antagonism of 627
Histiocytosis See also Miliary TB
HIV clinical 432
Hodgkin’s lymphoma 452, 454
HOMA index See also Homeostatic model assessment index
Homeostatic model assessment index 483
Homocystinuria 157, 548
Homovanillic acid 889
and other investigations, results of 510t
investigations 473t, 519t
results of 508t
profile FSH 532
replacement therapy 35
Hospital-acquired methicillin-resistant staphylococcus aureus 669, 669t
Hospitalization in pediatric population 81
vaccination 90
vaccine See also Human papillomavirus vaccine
H-type fistula demonstrated on bronchoscopy 832f
chorionic gonadotropin stimulation test 358
herpesvirus 7, 858
immunodeficiency virus 174, 248
test for 910
intravenous immunoglobulin 864
leukocyte antigens 255
papillomavirus vaccine 83, 84
Hutchinson’s sign 845
Hyaline bodies 857
Hydroxy progesterone 510
Hydroxychloroquine 570, 579, 586
Hydroxyprogesterone 499
Hyperactive disorder, attention deficit 54, 627, 740
Hyperactivity disorder 164
Hypercalcemia 495
Hyperchloremia 300
Hyperekplexia 162
Hypergonadotropic hypogonadism 524
causes of 525
Hypergranulation tissue 815
Hyperinflated lungs 236f, 238
Hyperkeratotic follicular papules 66
Hyperoxia test 17, 201
Hyperpigmentation 512f
Hyperpigmented spots on face 445f
Hyperreactive airway disease 279
Hyperresonant chest 245
Hypersensitivity pneumonitis 229, 231
Hypertension 427, 618
nephritis 301
obstructive cardiomyopathy 215
pyloric stenosis 15, 890, 891f
Hypertrophied nasal mucosa 599
Hyperuricemia 148, 220
Hypocalcemia 63, 67
microcytic anemia not responding to iron therapy, causes of 398
red blood cells 225
Hypoglycaemia 76, 512, 544, 631
sign of 19
symptom of 19
Hypogonadotropic hypogonadism 524
causes of 524
Hypokalemia 300, 495
Hypomagnesemia 220
Hypophosphatemia 67
hair 71
patch 841f
Hypoplasia 187
Hypoplastic 413f
Hyposmia, history of 773
Hypotension 618
Hypothyroidism See Cushing syndrome
Hypotonia 544
Hypovolemic shock 684
Hypoxanthine-guanine phosphoribosyltransferase enzyme 147
Hypoxic ischemic encephalopathy 28
Hypsarrhythmia 160f, 162
Hypsarrhythmia See Multifocal epileptiform activity
Idiopathic 817
aplastic anemia 413
thrombocytopenic purpura 317, 577
Ileocecal opening with ulcers 289f
IM pheniramine maleate 681
Imferon See Iron dextran complex
Iminodiacetic acid 277
Immediate intervention, management 681
deficiency 118
tolerance 285
Immunization 79
Immunobullous disorder 873
Immunodeficiency with pneumocystis Carinii pneumonia 910
Impacted wax 787
Impedance audiometry 779
Impetigo 871
Impulse control disorder 743
Inactivated poliovirus vaccine 13, 84
Increased internipple distance and ptosis of right eye 531f
Indian infants, development assessment scale for 38
Indian Pediatric Nephrology Society 314
Ineffective erythropoiesis 395
Infancy 474
Infant with
abdominal swelling 459
congenital hypothyroidism 505
jaundice 276f
nonreducible groin swelling 814
untreated congenital hypothyroidism 506f
colic 162
esotropia 754
hemangiomas, treatment of 32
pyloric stenosis 890
variety 301
tremor syndrome 70
Infantogram multiple diaphyseal fractures 539f
Infected necrosis, treatment of 666
Infection-induced asthma 603
Infectious disease 93
society of america 668
Infectious mononucleosis 101, 906, 907
Inferior turbinate 804
Inflammatory bowel disease 72, 75, 258, 259
Infliximab 570
Infliximab See Anti-TNF therapy
Inguinal hernia 557, 814
in infant 360
incidence of 811
Innocent pulmonary murmur 193
Inotropes infusion, preparation of 677
infusion 672
levels of 478
like growth factor-1 472
Integrative phase 285
Intellectual disability 558
Intelligence quotient 738, 742
Intensive care 649
Intercostal retractions 239f
Intermittent exotropia 761, 761f
management of 762
Internal carotid artery 805
bilirubin 10
sepsis screen 22
Interstitial lung disease See Hypersensitivity pneumonitis
lipase, inhibitor of 484
malabsorption 75
polyps, multiple 445
Intracranial space occupying lesion 475
Intradermal injection 918
ceftriaxone 104
injection 915
Intraocular lens 768
access 919
cannulation 920f
Intrauterine growth restriction 6, 277
access in infants and young children, different sites for 917f
cannulation 916
fluids 689
immunoglobulin 584
course of 87
role of 13
use of 670
methylene 625
methylprednisolone 581
Intubation, indications for 661
Intussusception 892, 893f
Iodine deficiency 69
disorder 69
Ipratropium, inhalation of 599
Iron 619
amino acid chelates 74
binding capacity 73
anemia 72, 75, 437
cause of 435
hematological differentiation of 73t
symptom of 435
causes of 435
dextran complex 75
formulations in Indian market 74t
of heme 625
polymaltose complex 74
sorbitol citric acid complex 75
Irreducible hernia 361
Irregular colonic ulcers 260f
Irwin-Moore’s sign 783
Ischemic stroke causes 157
Isoimmune hemolytic disease 11
Isolated growth hormone deficiency 474
Isomorphic phenomenon See also Koebner’s phenomenon
Isoniazid 29, 619
Issues related to
chronic illness 724
puberty 718
Issues with parents 710
Itchy skin lesions 876f
over face 871f
Itraconazole 868
IV hydrocortisone therapy 511
Japanese B encephalitis 183
Jaundice 9, 35, 283
Jaundice See also Blood transfusion
history of 407
Jittery neonate 18
Joulies solution 301
Jugular venous pressure 193
angiofibroma mass 804
dermatomyositis 584
idiopathic arthritis: polyarthritis 567
nasopharyngeal angiofibroma 803805
Karyotype 526, 557
trisomy 21 552f
Kawasaki disease 130, 572, 593, 594, 909
Kayser-Fleischer ring 272f, 544
Kearns-Sayre syndrome 760
Keratomalacia 62
Keratosis pilaris 875
Ketonemia 672
Ketonuria 672
Keyhole sign 372
Kidney 114, 378
problem 316
stones, symptoms of 375
ultrasonography of 377f
Ureter-bladder 26
Kiesselbach’s plexus 799
Killed vaccine See Live vaccine
Klebsiella 12
Kleihauer-Betke test 431
demonstrated acid resistant pink colored fetal RBCs in mother’s smear 421f
Klinefelter’s syndrome 548
Knee swelling 461
Koebner’s phenomenon 857, 862
Koebnerization 856
Koyanagi urethroplasty 382
Krabbe disease 171
Labial adhesion 388, 389
manual release of 390f
Laboratory abnormalities 594
Lacrimation 617
Lame ducks 706
Langerhans cell histiocytosis 495
Language evaluation scale trivandrum 35
Large right renal calculus 374f
Laryngeal edema 608
Late hemorrhagic disease of newborn 424
Late onset cyanosis 19
Lawrence-Moon-Biedel syndrome 482, 524
Lead 619
poisoning 433
disability 738
features of 733
disorders 729
points 83
acute suppurative otitis media 775
coronary artery from pulmonary artery, anomalous 214
origin of 213
examination 775
otomycosis 791
facial palsy 149f
hemiplegia 153, 154f
hydroureteronephrosis 371
inguinal hernia 361f
in a-male-infant 811f
kidney 313
anteroposterior 315f
uptake in 310f
with normal right kidney 311f
lower ureteric calculus 305f
nonpalpable UDT 357
ovarian yolk sac tumor 464
pelvicalyceal system duplex 895
pelviureteric junction obstruction 367
renal neoplasm 458f
sided undescended testis 357, 357f
tympanic membrane in stage of congestion 785f
ventricle dysfunction 197f
ventricular hypertrophy 216f
Lentiform nucleus, obscuration of 154f
Leopard syndrome 853
infection 115
interrogans 115
Leptospirosis 114
Lesbian involvements in heterosexual girl 707
Lesch-Nyhan syndrome 145, 147, 148
Lethargy 625
Leucopenia 901
Leukocoria 767
Leukocyte 66
common antigen 460
count 22, 234, 268, 567, 901
differential 567
Leukocytosis 901
Leukopenia 248, 576
Leuteinizing hormone 487
Levator palpebrae superioris muscle 758
Levocetirizine 808
Libman-Sacks endocarditis 578
Lichen planus 861
Lidocaine 625
Life-threatening asthma 655
Limb anomalies 418f
Linear burning skin lesions over right forearm 848f
Lipid storage disorder 290
Lithium manganese 635
Live oral vaccine 85
Live vaccine 86
Livedo reticularis 578, 592
disease 273
decompensated 272
function tests 38, 531
jaundice 114
just palpable 35
transplantation 645
Long QT syndrome 217, 219
Loose motion, history of 426f
Lorazepam 227
dose antibiotic prophylaxis 386
molecular weight heparin 156, 177
self-esteem 746
serum-ascites albumin gradient 288
Lowe’s syndrome 300
abdominal pain 444
limb, deformities of 67
motor neuron 173
bifacial palsy 172
punctum in both eyes 765
segment caesarean section 185
Low-molecular-weight heparin 322
Low-resource settings, treatment in 674
Lumbar puncture 179, 921
in child 922f
Lump in left flank 368f
anticoagulant ratio 155
erythematosus 577
laboratory diagnosis of 577
nephritis 580
with arthritis 575
with hematological involvement 583
Luschka’s tonsils 793
Lymphadenopathy 402
Lymphoma See Food allergy
Lymphopenia 576
audouinii 867
canis 867
distortum 867
ferrugineum 867
gypseum 867
nanum 867
Macrocytic anemia 395
Macrolides 104
Macrophage activation syndrome 572
Magnetic resonance
cholangiopancreatography 667
venography 321
Maintenance intravenous fluids 671
Major aortopulmonary collateral arteries 210
Major bleeding, management of 691
Malabsorption See also Chronic anemia
syndrome 62, 64
Malaise, history of 583
Malaria 430, 907
AG test 126
Male child presenting with precocious puberty 498
Males, cause common to 525
Malrotation of gut 14
Manganese dioxide 635
Mantoux test 173, 230
Marcus Gunn jaw-winking phenomenon 758
Marfan’s syndrome 545, 548, 757
Marfanoid habitus 546f
Massive hepatomegaly 285
Masturbation, behavior change to 720
autoimmune thyroid disease 505
uniparental disomy 563
Mccune-Albright syndrome 500
arterial pressure 679
hemoglobin 567
volume 71, 567
Measles 84
Meckel’s diverticulum 72, 828, 829f, 893
Meconium aspiration 24
Medial frontal hyperintensity 181f
lymphoblastic lymphoma 455
mass 454
differential diagnosis of 456t
widening in non-Hodgkin lymphoma 455f
Medical cases 718
Medulloblastoma 465
and ependymoma, comparison of 151t
Mega cisterna magna 188
Megakaryocytes, presence of 422
Megalencephalic leukoencephalopathy 170
Megaloblastic anemia 393, 395
causes of 395
Menarche 489
Meningitis See also Treating sepsis
infection 114
vaccination 90
Meningococcemia 112, 113
Menstrual bleeding See Menarche
disorders, manual of 48
health issues 697
retardation 559
definition of 735
status 179
Mercaptoacetylglycine 369
oxide 635
toxicity 636
adenopathy 268
cyst leading to volvulus 826f
lymphadenitis 269
to left portal vein bypass 265
acidosis 543
to tissue hypoxia 626
derangements 583
disorder, approach in suspected case of 545
liver disease 273
risk factors, investigations for 480t
criteria of 480
development of 482
in adolescents, definition of 483t
workup 376
Metabolisms, inborn errors of 768
Metformin 485
Metformin See Biguanides
poisoning 632
Methemoglobin 619
Methemoglobinemia 624f
acquired causes of 625
Staphylococcus aureus 669
treatment of 669t
strains of S. aureus 668
Methylene blue 626
Metoclopramide 625
Metronidazole 226
Microangiopathic hemolytic anemia 428
Microcytic hypochromic anemia 431, 435
Microscopic hematuria 304
Microspherocytes, presence of 408f
Microsporum canis 867
cystourethrogram 313, 366f, 371, 371f
Mid-clavicular line 278
aeration 781
infection 608
lobe syndrome 604
Midnight cortisol 484
Midperipheral retina 760
Migraine 159
asthma 655
facial dysmorphism 141
mental retardation 734, 735
neutrophilic leukocytosis 95
respiratory distress 245
thrombocytopenia 584
TB 125
tuberculosis, diagnosis of 231
Miller Fisher syndrome 177
Millon adolescent personality inventory 717
Minocycline 843
Miosis 617, 618, 647
Mixed bag 89
Moderate acute asthma 655
Moderately cellular glial tumor 151f
Molecular for FGFR3 gene mutation 537
Möller-Barlow disease 65
bodies See Hyaline bodies
contagiosum 856
virus 857
with koebnerization 856
Mometasone nasal spray 610
Monocytes 901
Monocytosis 248, 902
Moraxella catarrhalis 104, 776, 786
Mother of child with dengue 690f
MR, definition of 735
MRSA See Methicillin-resistant Staphylococcus aureus, treatment of
Mucosal telangiectasias 817
Müllerian ducts 383
Müllerian-inhibiting hormone 383
Multicystic dysplastic kidney 309
Multifocal epileptiform activity 160
Multinucleated giant cells 844
bilateral petechiae 423f
café-au-lait spots 308f, 309f
congenital anomalies 39
depigmented lesions 865f
erosions 878f
fluid filled lesions over upper limb and trunk 873f
itchy pigmented lesions 861f
lesions 858f
ligation probe amplification 558
patches of loss of hair 846f
pituitary hormone deficiency 475
raised lesions 856f
with rough surface 875f
stereotypic movements 148
Mumps 907
and rubellas 84, 681
Munchausen’s syndrome 849
by proxy 849
Muscarinic receptors 647
Muscle biopsy 143, 586
intense pas positive deposits within vacuoles 142f
Mutilation of lip and excoriation 146f
Myalgia 65
Mycobacterium leprae 842, 843
Mycophenolate mofetil 584
Mycoplasma 907
antibody 173
Myelodysplastic syndromes 419
Myocardial dysfunction 271
Myocarditis 594
Myopia 756, 756f
Myringotomy with grommet insertion 780f
Myxopapillary ependymoma 152
N-acetyl cysteine dosage regimens 645
IV regimen 645
oral dose 645
Naphthalene 619
Narrowed subglottic airway 233f
decongestant 776
flaring 141f
polyposis 773
polyps 774
septum 804
turbinates 237
Nasogastric tube 239, 922
in child 923f
insertion 922
Nasolacrimal duct 765
Nasopharynx, X-ray 786
Cholesterol Education Program 483
Family Health Survey 72
Nausea 681
history of 442
ipratropium bromide 658
salbutamol 658, 681
Necrotizing enterocolitis 818
Needle stick injury 86
Negative coombs test 429
Neisseria meningitidis 91, 113
cholestasis syndrome 276
encephalopathy 27
hepatitis 277
hypoglycemia 18, 51
intensive care unit 24, 39, 141, 167, 371, 432
period 544
respiratory distress syndrome 599
stroke 27
Nephritic syndrome 156, 296, 320, 688
Nephritis 578, 581
Nephrology 293
Nerve conduction velocity 143, 169
Neurobehavioral symptoms 148
Neuroblastoma 459, 889
in 9-month-old child 889f
marks See also Dysmorphism
syndromes 162
Neuroglycopenia 631
Neurohypophysis gene defect 493
dysfunction 148
examination 179
Neurology 139
Neuronal migration abnormalities 162
bladder 384
pain, management of 177
disease 581
lupus 581, 582
manifestations 583
Neutropenia 901
Neutrophilia 901
Neutrophilic leukocytosis 226
Neutrophils 901
intolerance of 253
ruling out hydrocephalus 4f
screening 30
with adrenal crisis 509
with CHD 212t
Newcastle control score 761
Nicotine 714
Nicotinic receptors 648
Night blindness 62
Nipah virus 183
Nirtroprusside 625
Nitrates 625
Nitrazepam 163
Nitric oxide 625
Nitroglycerine 625
lung disease 247
lymphoid hyperplasia 257f
Nodules 840
Noisy breathing 99
Non-cavitatory pulmonary disease 122
Nonallergic atopic rhinosinusitis with small airway obstruction 604
allergic rhinosinusitis 605
viral-induced asthma 610
phenotype 611
pneumonitis, treatment for 243
sepsis 25
Nonbullous ichthyosiform erythroderma 869, 870
Nonconsanguineous marriage 486
Nondistended abdomen 15
NonHodgkin’s lymphoma 454
Noninvasive ventilation 623
Nonmetastatic osteosarcoma 462
Nonpalpable testis 357
Nonreplicative 285
Nonsteroidal anti-inflammatory drugs 569, 686, 849, 862
Nontender lymph nodes 575
Nontypable haemophilus influenzae 104
Noonan syndrome 474
Noradrenaline infusion 677
Norepinephrine reuptake inhibitor 741
blood 624f
right kidney 310f
saline 689
spine 188f
anemia 64, 290
normochromic anemia 863
Northern hemisphere vaccine 82
Nose 554
examination 775
NSAIDs See also Nonsteroidal anti-inflammatory drugs
Nucleated red blood cells 23
Numerous keratocytes 225
anemia 71, 72
obesity, management of 484
rickets 41, 42
diagnosis of 67
Obese boy with body mass index 837
Obesity syndromes 485
Obstructive pulmonary disease 247
Occipital meningocele with Dandy-Walker malformation 185
Occulta See also Spina bifida cystica
Octreotide 631
action of 632
role of 666
Ocular manifestation 65
Oculocutaneous melanin pigmentation 445f
Ofloxacin 843
Oligoarthritis onset 568
Oliguria 302
history of 296
One testis in scrotum, absence of 5
OPD for yellow eyes 9
evaluation 36
examination for cystine 300
vein 803f
Opiates 619
atrophy syndrome 495
nerve or central nervous system 766
Optimal health supervision for children with Down syndrome 554t
13-cis-retinoic acid 840
albendazole, dose of 74
injection of 594
iron therapy 74, 75
polio 84
vaccine 10, 85
polyethylene glycol 283
propranolol 71
rehydration solution 76
ulcers 254
Organophosphate compounds 618
Origin of left coronary artery from pulmonary artery trunk 214f
Ornithine transcarbamylase deficiency 157
Ortolani test 35
diarrhea 253
fragility, increased 408f
Osteogenesis imperfecta 538
Osteosarcoma See Knee swelling
of lower end of femur 462f
primum ASD 195
secundum atrial septal defects, echocardiography of 195f
Otitis media with effusion 778
Otoacoustic emission 36, 40
Otomycosis 790
Otorhinolaryngology 771
mass 463
volume 488
Ovaries 490
Overdose to errors, prevention of 645
Oxalates in urine See High uric acid
Oxygen 626, 665
saturation 655
P vivax malaria 128
transfusion 400
volume 218
red blood cells 689
history of 449
site of 266f
lesion over scalp 867f
red patches on skin 850f
Pale looking child 420f
Pallor anomalies 418f
dosage 541t
treatment 540
Pancreas system 246
enzyme replacement 666
steatorrhea 666
Panton-valentine leukocidin 668
Papules over face 839f
Paracetamol 99, 104, 619
Paraneoplastic symptoms 890
Parathormone 42
Parenteral iron therapy 75
Paroxysmal nocturnal hemoglobinuria 414
pressure of oxygen 663
thromboplastin time 424
villous atrophy 255f
Particularly respiratory failure 665
Parvovirus infection 403
Patchy pneumonia especially in mid-zones bilaterally 228f
Patent ductus arteriosus 22, 193, 887
Paul-Bunnell test 906
Peak expiratory flow 655
Pedal edema See also Oral ulcers
advanced life support 615
brain tumor 152
endocrinology 469, 723
intensive care unit 178, 230, 628, 660, 679
obesity 485
management of 484
oncology 447
ophthalmology 751
rheumatologist 569
septic shock 679
algorithm 680
differ from adult septic shock 676
urology 359
Pelvicalyceal systems 895
Pelvis 537f
ultrasound of 490
Pelviureteric junction 315
obstruction 315
cases of 314
Pendrin-pendred syndrome 505
Penicillamine 435
Penicillin-binding protein 668
Penile curvature 359f
Peptic ulcer disease 266
Percutaneous nephrolithotomy 375, 376
Pericarditis 594
acid schiff reagent 286
fever syndromes 572
lateralizing epileptiform discharges 179
Periorbital granulocytic sarcoma 451f
hemangioma, presence of 652
nerve disorders 174
nervous system 582
venipuncture 918
Peritoneal pathology 288
anemia not responding to treatment, complains of 436f
hyperglycemia 674
hyperinflation 235f
oligoarthritis 568
pneumonia 108
pulmonary hypertension in newborn 198, 199
Personality issuses 715
Pertussis 908
Pes planus 547f
Petechial rash 316
on legs 316f
Peutz Jegher’s syndrome 281, 442, 444
Pharyngeal mucosa, injection of 594
Phenobarbitone 71
Phenotypic penetrance 838
Phenytoin 29
Phimosis 362
Phosphopenic rickets See Hypophosphatemia
Phosphorous 41, 42, 296
Photochemotherapy 847
Phrynoderma 874
PICU, progress in 675
Pimecrolimus 866
Pinneau method 491
Pityriasis rosea 857, 858
Plasma amino acids 162
falciparum 412, 911
malaria 911
vivax 431
malaria 127, 412
Platelet 296
transfusion 691
Playground in preprimary 744
Pleural effusion 119, 247
complicated 108
Pluckable sign 846
conjugate vaccine 81
dose of 223
serotypes, common 81
vaccine 103
Pneumocystis carinii pneumonia 910, 911
Pneumomediastinum 634f
Pneumonia 91, 905
with empyema 106
Pneumonitis in systemic lupus erythematosus 243f
Pneumothorax 634f
Poisoning 613
Polyarteritis nodosa 303, 572, 591
Polyarthritis onset 568
Polycystic ovary syndrome 481
Polydipsia, approach to case of 494
Polyethylene glycol 618
Polymerase chain reaction 179
left nasal cavity 773f
rectum 280
Polyuria, approach to case of 494
Pompe disease 143, 144
facial muscle tone 141f
learning environment 731, 732
prioritization 700
self-esteem 699
Pornographic compatible disk 733
Portal hypertension 264
monospot test 102
swollen hepatocytes filled with glycogen 287f
fossa cyst 187f, 188f
urethral valves 370, 371
Postherpetic neuralgia 845
Postictal Todd’s paralysis 159
Postinfectious nephritis 302, 304
Postmeningitic sensorineural deafness 43
Postpolypectomy clean stalk 281f
Postprimary tuberculosis 884
Post-traumatic stress disorder 57
Pot belly See Protuberant abdomen
Potassium 296, 660
Prader Willi syndrome 474, 482, 560, 563
Prader Willi syndrome See Syndromic obesity
diagnostic criteria for 561
lymph node 763
tag 3, 3f
Precocious puberty
in girls 489
management of 491
Pre-discharge checklist for jaundice 10t
Prednisolone 584, 593
comedones 840
cysts 840
pustules 840
Pregabalin 177
Pregnancy-associated plasma protein A 553
Pregnancy-induced hypertension, history of 199
rupture of membranes 23
thelarche 520
Prenatal diagnosis 542
Presinusoidal extrahepatic portal venous obstruction 264
Pretransfusion hemoglobin 401
Prilocaine 625
Primaquine 625
dynamic obstruction 821
and adynamic obstruction, differentiating between 821t
hypoadrenalism 513
microcephaly 37
posterior capsulorhexis 768
tuberculosis 883, 884
Primitive neuroectodermal tumor 456
Prism diopters 754
Progeria 853
Prolapsing rectal polyp 819
Prophylactic antibiotics in necrotizing pancreatitis, use of 666
Protein 567
energy malnutrition 76
Proteus 25
Prothrombin time 911
Proton pump inhibitors 279
Protuberant abdomen 67
Pseudocyst mid body of pancreas 271f
Pseudohypoparathyroidism 474
aeruginosa 776, 786
species 25
Pseudoparalysis 66
Psoralen ultraviolet A 841
Psoriasis vulgaris 859, 860
Psoriatic arthritis 568
issues 697
short stature 474
Pterygoid plexus 803f
Pubarche See also Axillary hair
gynecomastia 718
years 474
Puberty, induction of 526
Pubic hair development 489, 499f
Puffiness gradually spread to whole body 428f
arterial hypertension 193
AV fistula 218
edema 239, 240f
with scorpion sting 238
exacerbations 245
hypertension of newborn 17
nodules with rheumatoid arthritis 246
tuberculosis 117, 118, 122
vasculitis 247
Pulsus paradoxus 229
Pure-tone audiometry 779
Pyopericarditis with tamponade 205
Pyrexia of unknown origin 920
Pyuria, history of 379
Quadrivalent vaccine 84
Quiet tachypnea 672
Rabies vaccination after pet dog scratch/bite 89
Rachitic rosary See Ribs, junction of
Rader-Willi syndrome 524
Radiculopathies 173
serum creatinine 295
warty lesion 868f
Ramsay Hunt syndrome 845
Rapid sequence intubation 657, 661
Rashes on upper extremities 317f
Raynaud’s phenomenon 567, 578
RDW values in various diseases 397t
Reactional states 842
Ready-to-use therapeutic foods 76
Rebellion 713
Receptive language 737
polyp prolapsing out 817f
prolapse 818f
Recurrent viral infection 98
blood cells 257, 576, 675, 901
aplasia 433
distribution width 397, 901
units 400
gastric aspirate 638f
urine 638f
Redness in perianal area 8f
Refractive error, correction of 762
Refsum’s disease 760
Refusal to sit in classroom 744
Remediation, principles of 740
biopsy 580
calculus 373
disease 304, 306
causes 298
diseases 303
failure 688
function tests 42, 531
pelvis 315
problems, history of 316
tubular acidosis 299
ultrasonography 365
Replicative phase 285
distress syndrome 25, 200
manifestations 681
in systemic diseases 238
Reticulocyte count 426
Retinal pigment epithelium 760
Retinitis pigmentosa 759
Retinoblastoma 765
Retinoblastoma group B 766f
Retrograde cholangiopancreatography 667
extension of granulocytic sarcoma 452f
pain 101
Retropharyngeal 653
abscess 652
Retrosternal pain 261
Rhabdomyosarcoma 456, 468
arising from bladder wall 467f
of prostate 467
Rheumatic fever 206, 207
arthritis 247
history of 246
interstitial lung disease, phenotypes of 246
with pulmonary nodules 246
factor positive 567
Rheumatology 565
Rhinolith in floor of right nasal cavity 778f
Riboflavin deficiency 64
Ribonucleic acid 275
Ribs, junction of 67
Rickets See also Vitamin D deficiency
Rickets, common cause of 43
Rickettsial infection 133
Rifampicin 29, 290, 843
Rifampin-resistant leprosy, treatment of 843
breast See Tanner staging
coronary artery 214
ear, examination 775
inguinal hernia in a-female-infant 812f
kidney 367
joint 317f, 878
swelling secondary to osteosarcoma 461f
modified blalock-taussig 40
nasal cavity 777
pelvicalyceal system 895
posterior tibial nerve conduction 176f
renal pelvic calculus 374
side hydrocele in a-male-child 814f
undescended testis with hypospadias 382f
upper lobe pneumonitis 278
hypertrophy 197 199, 209f, 211f
in infant with coarctation 197f
outflow trac 202
systolic pressure 200
Ringer’s lactate 689
Rituximab 586
use of 247
Romantic relationship 705
issue 704
Rosenberg self-esteem scale 699
Roseola 907
Rotaviral disease 82
Rotavirus vaccine 82
Rothmund-Thomson syndrome 853, 854
Round pneumonia 884, 884f, 885
influenza vaccination 82
vaccines 81
Rubella 907
infection 438f
Rumack-Matthew nomogram 644, 644f
Russell-Silver syndrome 475
S. aureus 872
bacteremia 112
infection 112
S creatinine 492
S potassium 492
S sodium 492
Sagittal MRI of
brain 188f
of spine 188f
Sajeevan’s predicament 748
Salbutamol 611
inhalation of 599
nebulization 601, 603
plus ipratropium 607
Salicylic acid 860
Saliva, drooling of 261
Salivation 617
Salmonella 25, 609
Salt intake, decreasing 375
Sandal gap 551f
Sandifer syndrome 162
Saphenous vein cut down 919f
Scabies 854, 855
Scaling of skin 870f
Scaly lesions over knees and hands 859f
Schwamman-Diamond syndromes 418
Schwartz formula 297
Scorbutic rosary 66
Scrotal hypospadias 382f
Scurvy See also Vitamin C deficiency
diagnosis of 66
Second heart sound, importance of 17
emotional problems 732
pyogenic infection 855
Second-line antibiotics 807
Secretory otitis media 780
Sedation and paralysis during ventilation 657
Selective serotonin reuptake inhibitor 746
Self-centered and adamant 717
Self-esteem 698
Sensorineural deafness with pervasive developmental disorder 49
Sensory axonal neuropathy 177
Sepsis 625
tests for 904
Septic shock 675, 684
bundles 680
intubated 678
versus dengue shock, comparison of 685t
Septicemia with central nervous system 112
Serotonin syndrome 617
Serratia 25
albumin 46, 567, 571
bilirubin 9
levels 11t
cholesterol levels 483
creatinine 426, 567
ferritin 443
folic acid 395
glutamate pyruvate transaminase 567
oxaloacetic transaminase 46, 230
oxaloacetic transaminase 567
pyruvate transaminase 46, 571
pyruvic transaminase 230
immunoglobulin E 655
insulin level 483
luteinizing hormone 723
protein 46
TSH 517
asthma 236
hemolysis 129
pancreatitis 663
asthma 655
bleeding 688
cardiotoxicity, presence of 629
chest pain 235
dengue 691
criteria for 688
infection 684
hemolytic anemia 412
intrauterine growth retardation 475
itching over genitals, complaints of 854f
malnutrition 75
myoclonic epilepsy in infancy 162
pain 636
papilledema bilaterally 149
perianal excoriation 253f
plasma leakage 688
rickets noted clinically with widening of wrists 299f
toxicity 647
tricuspid regurgitation 200f
Sex development, disorders of 358, 381
activity, history of 247
aversion 704
criteria for 704
confusion 708
maturity rating 531
Sexuality relationship issue 704
Shigella 609
Shock, management of 691
Short stature, treatment of 526
Sibutramine 484
child with ecchymosis 413f
newborn babies 23
Sickle cell
anemia 405f
disease 85, 158, 404
Silhouette sign, clearance of 604f
Silk glove sign 362
Silver oxide 635
Simian crease 6, 6f, 551f
Simple nutritional obesity 483
normal kidney with hypertension 308
stage urethroplasty 360
system ureteroceles 378
Skeletal survey 535
abnormality 544
allergy See also Middle ear infection
infection 667
manifestations 575, 681
symptoms 846
Skull lateral view large calvarium 536f
Slow learner 736
Small genitalia to obesity 721f
Snare polypectomy 281
predicament 747
progress 747
Sodamint 301
Sodium 296, 660
infusion 638
therapy 628
valproate 167
Soft tissue
infection 667
nasopharynx lateral view adenoid hypertrophy 793f
Somatostatin, role of 666
Something coming out per rectum 818
Speak of marriage 702
Specific learning disability, early indicators of 737
Spina bifida cystica 186
cord ependymomas 152
muscular atrophy 144
Spongiform leukodystrophy See also Canavan disease
Spontaneous abortions 532
Sputum for acid-fast bacillus 908
Squinting of
both eyes 755f
eyes 767
aureus 802
cassette chromosome MEC 669
sepsis 110
Staphylococcus aureus 231, 667, 668, 670, 776, 786, 872
Star struck 702
Starter formula (f-75), composition of 77
Status epilepticus 658, 659
Steeple sign 233, 233f
Steroids 682
Stevens-Johnson syndrome 862, 863, 864
Stickler’s syndrome 757
Stimulant drug 741
Straight leg raising 678
Strain 199f
Strangulated inguinal hernia with
ovarian gangrene in a-female-infant 813f
resultant bowel gangrene 812f
Strangulation in right inguinal hernia in a-female-infant 813f
Streaky lesion, clearance of 604f
pneumoniae 104, 776, 786, 885
pyogenes 776, 786, 872
Stridor 681
Stridor See Upper airway obstruction
Stroke 153
Sturge-Weber syndrome 754
Subclinical asthma 607
Subcutaneous injection 916
Subependymoma 152
Subpulmonic VSD, management algorithm of 205
Subsequent ventilator management 657
Substance abuse 714
Subtelomeric 558
cardiac death 215
deterioration 21
Suicidal ideation 746
in adolescence 746
Sulfite oxidase deficiency 157
Sulfonamides 625, 874
agent poisoning 630
dose of 632
induced hypoglycemia 632
overdose 631
Sun protection factor 579
Supracardiac total anomalous pulmonary venous connection 209f
Supraclavicular lymphadenopathy in Hodgkin lymphoma 453f
Suprasystemic pulmonary artery 200
Supratherapeutic overdose 645
Supraventricular tachycardia, diagnosis of 201
Surface anatomy markings of both lungs 105
Surgery 809
Survivor motor neuron, analysis of 144
genetic causes of obesity 562
labial adhesions 389f
osteogenesis imperfecta 538f
Swelling over hands 404f
Swyer-James syndrome 887
Symbolic play, level of 737
Symmetrical diffuse goiter in child with hashimoto thyroiditis 517f
Sympathomimetic toxidrome 617
Symptomatic hypoglycemia 630, 631
Synchronized intermittent mandatory ventilation 657
Asperger 744
Bardet-Biedl 760
Bland-Garland-White 215
Cockayne 853, 854
Cornelia de Lange 148
Cushing 474, 481, 485, 578
Dandy-Walker 186, 189
de Sanctis-Cacchione 854
deafness 495
dengue shock 96, 97
Didmoad 495
Down’s 474, 549
Dravet 162
Ehlers-Danlos 548
Eisenmenger 215
Evans’ 578
Fanconi 299, 300
Felty’s 570
Foremilk 8
Fragile X 558f
Gardner’s 281
Goldenhar 51
Goodpasture’s 244, 303
Guillain-Barré 171, 173, 175, 177t, 275, 582
hemolytic uremic 225, 318, 425, 427, 428, 429
hemophagocytic 248
in infant, aspiration 831
Kearns-Sayre 760
Klinefelter’s 548
Laurence Moon Biedl 482, 524
Leopard 853
Lesch-Nyhan 145, 146f, 147, 148
Marfan’s 545, 548, 757
Mccune-Albright 500
metabolic, criteria of 480
Miller Fisher 177
Munchausen’s 849
myelodysplastic 419
neonatal respiratory distress 599
nephritic 156, 296, 320 688
neurocutaneous 162
obesity 485
optic atrophy 495
periodic fever 572
Peutz Jegher’s 281, 442, 444, 445f
polycystic ovary 481
Prader Willi 474, 482, 524, 560, 561f, 563
Ramsay Hunt 845
respiratory distress 25, 200
Rett 559f
Rothmund-Thomson 853, 854
Russell-Silver 475
sandifer 162
Schwamman-Diamond 418
Stevens-Johnson 862, 863, 864
Stickler’s 757
Sturge-Weber 754
Swyer-James 887
toxic shock 594
Turner 526
Weil’s 115
Werner 853
West 159
William 556, 559
Wolff-Parkinson-White 144, 202, 217
Wolfram 493
Syndromic obesity 481, 483
Synkinesis, type of 759
antibiotics, courses of 840
diseases 303
inflammatory response syndrome 676
lupus erythematosus 576
onset juvenile idiopathic arthritis 571
vascular resistance 676
Systolic blood pressure 199
T soudanense 867
T verrucosum 867
T violaceum 867
Tachycardia 427, 618
Tachycardiomyopathy 215
Tachypnea 427, 618
Tacrolimus 415, 860, 866
Takayasu arteritis 590
Tandem mass spectrometry 558
staging 471, 522
staging of sexual maturity 521
whitehouse method 477, 491
Tazarotene 860
meningitis 123
pleural effusion 121
TCA overdose, complications of 628
TDAP vaccine 91
Temporary lactose intolerance in newborn 253
Tender subcutaneous nodules 592
Terbinafine 868
Terbutaline See also Adrenaline
biopsy 592
causes 500
torsion 380f
volume prepubertal 499f
Tetracycline 840, 874
Thalassemia 400
case of 401
intermedia 401, 402
major 396, 398
minor 73
Thanatophoric dysplasia 540
Thematic apperception test 714
Therapy with hypertonic saline 629
Thiamine deficiency 62
generation pedigree 546f
phases of dengue 686
Thrive in infants, failure to 297
Throat 554, 773, 807
Thrombocytopenia 576, 584
Thrombolytic therapy for childhood stroke 159
Thrombotic thrombocytopenic purpura 578
Thryroid ultrasound, interpretation of 509t
Thumb sign 547f
binding globulin 70
dysfunction 553
dysgenesis 505
function tests 36, 515t, 534
interpretation of 515
gland 30
profile 563, 846
stimulating hormone 30, 70, 297, 477, 487, 532
swelling 69
ultrasound 517
Tight foreskin 363f
Tightness of chest, symptom of 237
Time sensitive antiepileptic drug escalation protocol 660t
capsicum 847
iodine 847
Tinea capitis 846, 866, 867
Tissue transglutaminase antibody 255
Tobacco smoke 601
Tocilizumab 570
Toddler’s fracture 896
distal tibial diametaphysis 896f
Tongue tie 3, 3f
Tonsils 102
painkiller 843
retinoic acid 838
retinoids 838, 840
Topiramate 163
TORCH 439, 439t
infection 438
titers 38, 40
epidermal necrolysis 851, 864
shock syndrome 594
Toxidrome 616
common 617t
Toxins 661
common signs observed in different 618t
infection 438f
other agents, rubella, cytomegalovirus and herpes simplex See also TORCH
Tracheoesophageal fistula 636
Transient congenital hypothyroidism, causes of 505
Transilluminant cystic swelling of occipital region 186f
Transverse colon in child with Hirschsprung’s disease 823f
Treating sepsis 24
Trichophyton tonsurans 867
Tricyclic anti-depressant 618, 627, 628
Triglycerides 483
Trimethoprim-sulfamethoxazole 104, 112, 851
Trisomy 21 35
Trivandrum developmental screening chart 35
Tropical eosinophilia 907, 908
Tuberculosis 907
diagnosis of 126
signs of 123
with hemophagocytic histiocytosis 247
Tuberculous 288
problem 297
reabsorption of phosphorus 300
Tumor necrosis factor-α antagonist 247
Turner syndrome 198, 474, 475, 522, 524, 526, 532
features of 533
typical features of 523f
Tympanic membrane 779f
in stage of presuppuration 775f
in stage of suppuration 774f
Tympanogram 36
Typhoid vaccination after enteric fever 90
Typical lobar pneumonia in child involving right upper lobe 885f
Ulcerated plaque over right side of upper face 843f
Ulceration in perianal area 8f
Ulcerative colitis 260
with bronchiectasis 241
Ulegyria suggestive of postnatal hypoglycemic insult 161f
discharge 815
granuloma 815
polyp 815f
vein catheterization 921
Undescended testis 357, 381
Undifferentiated arthritis 569
Upper airway obstruction 651, 653
GI bleed 263
infection 653, 776
tract infection 775, 825
Ureter 378
Ureteric disease 306
Ureterocele 376
Ureterorenoscopy 376
Ureters, opacification of 895
Urinalysis 567
bladder 895
frequency 647
incontinence 617
infections 365
opening on underside of penis 359f
potassium 323
sodium 323
symptoms, history of 449
tract 15
infection 12, 159, 390, 894
from vesicoureteric reflux 894
vanillylmandelic acid 460
Urine 660
analysis 365
culture 12, 572
discoloration of 637
for amino acids 300
for microalbuminuria 726
organic acids 162
reducing substance 46
retention of 467
routine 265, 296
vanillylmandelic acid 889
VMA 173
Urology 355
Urticaria 681, 851
Usefulness of ScvO2 680
USS abdomen 38, 42
Uterus 490
Vaccination 86
after bone marrow transplant 88
in HIV infected child 84
under special clinical circumstances 84
with HPV vaccine 83
Vaccine-associated paralytic poliomyelitis 85
Vaginal opening, absent 389f
Valproate 163
Vancomycin 112
Vanishing white matter disease 170
Varicella-Zoster virus 135, 844
Vascular hemangiomas 32
Vasculitic disorders of children 588, 590
Vasovagal reaction versus anaphylaxis 683t
blood gas 492, 510
cut down 918
Ventilation, indication for 692
Ventilatory monitoring 657
Ventral penile curvature 359
Ventricular septal defect 196, 203, 204, 549, 886, 886f
Vermian hypoplasia 187f
consists of 187
conjunctivitis 762
keratoconjunctivitis 606, 764
Vesicoureteral reflux 371, 365
Vesicoureteric reflux 894
Vestibulitis 802
Vimentin 460
Vineland social maturity scale 35
clearance See Integrative phase
croup 232, 233
encephalitis 135
hepatitis 907
illness 95
infection 274, 902
complication of 97
myocarditis 207
Visual acuity 756
A 875
acid 840
deficiency 61, 875
disorder 61
B12 395
deficiency 441
B-complex 875
C deficiency 65
deficiency 66, 67
level 42
D2 42, 67
D3 67
D3 See also Cholecalciferol
E 875
K 29
antagonists 29
deficiency 29, 30
bleeding disorder 29
injection of 425
Vitello-intestinal duct 815
Vitiligo vulgaris 864, 865
Voiding cystourethrogram 385f, 894
Vomiting 594, 681, 894
history of 114, 442, 449
in newborn 819
neonate 14
Vulval synechiae See Labial adhesions
circumference 479, 483
hip ratio 479
Warfarin 29, 619
Water deprivation test
interpretation of 497t
limitations of 496
Waterhouse Friderichsen syndrome 91, 513
Wax occluding ear canal 787f
Weak pulses 615
Weaning 657
Weber-Ferguson incision 806
intelligence scale for children 741
memory scale 700
Wegener’s granulomatosis 110, 303
Weil’s syndrome 115
Werner syndrome 853
nile virus 183
syndrome 159
blood cells 225, 575, 901
cell count 901
stools suggestive of biliary atresia 277f
blood 689
bowel irrigation 618
Whooping cough 916
Wickham’s striae 861, 862
William syndrome 556, 559
Wilms tumor 457
of left kidney 458
Wilson’s disease 272, 273, 274, 300
Wolff-Parkinson-White syndrome 144, 202, 217
Wolfram syndrome 493
Work-up of child with cataract 555
Worsen cerebral edema 673
Wrist sign 547f
Xeroderma pigmentosum 852, 853
Yersinia 269
air cells 635
binding ligandin 68
deficiency 68
malabsorption in intestine 69
Chapter Notes

Save Clear

NewbornSection 1

Section Editors Rhishikesh Thakre,
Naveen Jain
Contributors Rhishikesh Thakre,
Naveen Jain
Reviewer Dhanya Dharmapalan
Section Outline
OPD Problems—Normal or Abnormal?
Jittery Neonate
Role of Growth Charts
Late Onset Cyanosis
Foremilk Syndrome
Sudden Deterioration
Assessing ‘Risk Factors’ for Significant Jaundice
Interpreting Sepsis Screen
Interpreting Bilirubin
Treating Sepsis or Meningitis?
Nonbacterial Sepsis
Role of Intravenous Immunoglobulin (IVIG)
Neonatal Encephalopathy
Vomiting Neonate
Bleeding Neonate
Dehydration in a Neonate
Newborn Screening
Importance of Second Heart Sound
Using Propranolol
You are asked to evaluate in well baby clinic the following patient concerns.
Case 1A: Tongue Tie (Fig. 1)
zoom view
Fig. 1: Tongue tie
True tongue tie is a very rare condition. To some extent tongue tie is normal in every newborn baby and it rarely interferes with either sucking or later speech development. The tongue tie diagnosis rests primarily on observation and analysis of feeding difficulties rather than the static appearance of the tongue. There is no justification for actively searching for tongue tie during routine examination, but when mothers are having difficulty in breastfeeding this should be considered as one of several possible causes. Frenotomy is indicated only when there is associated breastfeeding difficulty.
Case 1B: Preauricular Tag (Fig. 2)
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Fig. 2: Preauricular tag
Preauricular tags are common minor congenital anomalies. In isolation they do not appear to be pathological. However, one should look for presence of other congenital anomalies and, if present, must screen for hearing by otoacoustic emission (OAE) and genitourinary anomalies by means of ultrasound study. In isolated preauricular tags or sinuses one need not do any further evaluation. One must consider hearing evaluation in such infants.
Case 1C: Newborn has been Referred for Ruling Out Hydrocephalus. He has Setting Sun Sign (Fig. 3)
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Fig. 3: Newborn ruling out hydrocephalus has setting sun sign
Setting sun sign is due to enlarged ventricles. The classical signs of hydrocephalus are increased head circumference, sutural separation, wide and tense anterior fontanel. All signs together suggest hydrocephalus. None of these signs in isolation is diagnostic of hydrocephalus. Infants up to 3 months of age have setting sun sign due to immaturity of upward gaze eye muscles. If the head circumference is normal, setting sun sign may be physiological. No evaluation is needed. Follow-up of head circumference is the only evaluation needed.
Case 1D: Parents are Concerned about Bowing of Lower Limbs (Fig. 4)
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Fig. 4: Bowing of lower limbs
Bowing of legs in isolation in a well growing baby is a physiological finding. Since the majority of babies are born headfirst, they spend the last weeks in the uterus with their legs crossed and folded against their abdomen. This results in a bowing of the still very soft fetal leg bones. This usually disappears by 2 years of age.
Case 1E: Absence of One Testis in the Scrotum
Testis should be normally palpable in both the scrotum at term. Inability to palpate testis in scrotum may indicate abnormal descent of testis. Many a times the testis is retractile and just below the deep inguinal ring and can be coaxed into the scrotum. The position of testis is normal and does not warrant further evaluation. However, testis in the inguinal canal or absent testis needs surgical consultation.
Case 1F: Inability to Retract the Prepuce and Scheduled for Circumcision
Phimosis is inability to retract the prepuce leading to urethral obstruction. Physiologically up to 2 years the prepuce is non-retractile and no attempt should be made to forcible retract it. This is a physiological finding and does not merit evaluation or surgical intervention.
Case 1G: Cortical Thumb (Fig. 5)
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Fig. 5: Cortical thumb
Cortical thumb is adduction of thumb with the palms. It is considered as a soft marker for neurologic abnormality and suggests possibility of underlying central nervous system (CNS) pathology. However, in first 3 months, bilateral cortical thumb is physiological and does not merit further evaluation. Persistence of cortical thumb is pathological beyond 3 months of age.6
Case 1H: Simian Crease (Fig. 6)
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Fig. 6: Simian crease
A single transverse crease of the hand is called simian crease. It is most commonly seen in Down's syndrome. Presence of isolated simian crease is not pathological; up to 5% of normal newborns may have it. At times it may be familial. Dysmorphic features with generalized hypotonia are pathognomic of Down's syndrome. Isolated simian crease warrants no genetic testing.
Certain clinical findings raise false alarm in newborns. Interpretation of these signs in isolation may lead to unnecessary referral or investigations.
Case 2A
Term baby delivered at 2.9 kg had a small appearing head; head circumference was 30.5 cm. Concerns were expressed to the family. A magnetic resonance imaging (MRI) was planned, but parents preferred to wait for 2 weeks. Two weeks later the baby's head circumference was tracking on the same 3rd centile line. The grandmother who accompanied also had a small head. The baby was followed to 2 years age; the head remained small; tracking the 3rd centile line on the growth chart. The baby's development was normal.
Case 2B
Term baby 2.2 kg at birth, had a head circumference of 34 cm; length of 45 cm. The baby was labeled as intrauterine growth restriction (IUGR) by the unit on discharge record. Baby continued to grow 7as a small infant and was seen at development clinic at 10 months age for failure to thrive and development delay. On plotting the growth chart, the baby's weight although low was tracking the birth centile and the length also kept the line. The parents had a short stature as well. The head circumference was still over 50th centile. All milestones other than gross motor were normal: baby was not sitting well without support. Neurological examination was normal. Family was reassured. At 3 years the child was normal in development.
Small/big head.
Growth chart.
Case 2A
Head circumference is a well-known marker for brain growth and values out of range cause grave concern. But, it should not be evaluated in isolation. Serial records are more important. Values of head circumference must be compared with length centiles (Dine's formula). Dine's formula: the relationship between length and head circumference can be expressed by the simplified formula.
Head circumference (centimeters) = 0.5 length + 9.5 ± 2.5 (accurate for first year of life)
In the first case, if the head circumference was static or was slower on the growth chart than weight or length, then a diagnosis of small head is worrying.
Case 2B
We commonly see babies with small stature having ‘normal head circumference’ which is relatively large for weight and length. Such babies incorrectly get investigated for failure to thrive (FTT) or large head. If growth chart is serially marked, one will find all the three parameters tracking. The skin fat thickness (clinical assessment) is a good way to exclude FTT. Also, when head is relatively large and body small, the center of gravity is high and the infants take longer time to achieve milestones like head control, sit stand, etc.
There are many growth charts available. World Health Organization (WHO) growth charts are currently recommended all over the world.
Head circumference is to be interpreted after serial recording and in comparison to length centile. Have a look at the family before making growth interpretations.
Growth chart is a powerful and inexpensive tool. Monitoring of growth [weight, occipitofrontal circumference (OFC) and length, not just weight] at every visit is the duty of a pediatrician and is possibly the simplest tool that assures that no major medical illness is missed. Faltering growth must be investigated. Head circumference and weight, both must be interpreted against length.8
A 20-day-old newborn was brought to outpatient department (OPD) for the 3rd time with many complaints. Baby passes motion frequently with every feed and few drops of motion with every cry, cough and otherwise. Baby regurgitates small amounts of milk often and is cranky most of the time. Mother gives history that baby is sucking vigorously, but, only for few minutes, goes off to sleep and demands after an hour again. The baby's perianal area is red and ulcerated (Fig. 7).
Mother is educated that 1st milk (foremilk) is rich in ‘sugars’ and has short gastric emptying time, baby gets hungry frequently, but frequent feeding finds the baby with only little hunger. Baby sucks for a short while (<10 minutes) and gets only foremilk. Drinking only foremilk is the cause of frequent stool and regurgitation.
Mother gradually spaces the feeds to 2.5–3 hours, feeds the baby for 15 minutes from one breast in one sitting. The baby's symptoms rapidly improve.
Foremilk syndrome.
Good history.
Educating mothers on lactation by demand than by schedule, from one breast in one sitting and recognizing that every cry is not hunger is very important.
zoom view
Fig. 7: Ulceration and redness in the perianal area
At the age of 2–3 weeks, babies should settle to a rhythm of feeding at 2–3 hours interval.
Hindmilk is important for weight gain and is possibly a cure for ‘colic’.
At 72 hours, 34–36 weeks boy (2.4 kg) born to primigravida, mother's blood group A Rh +ve, uneventful spontaneous delivery, is brought to OPD for yellow eyes. His elder brother needed phototherapy for jaundice in neonatal period. He is breastfed and offered formula feeds at night. He weighs 2.2 kg. He appears alert, active, with stable vital parameters. Jaundice appears to be up to trunk. There is no local or systemic problem identified. Since the extent of jaundice is not much parents are assured and asked to come for vaccination.
He is brought 48 hours later with jaundice up to palms and soles. Total serum bilirubin (TSB) is 20 mg% and requires intensive phototherapy. Bilirubin drops to 16 mg% with phototherapy and lactation assistance. He recovers by day 7 to be discharged.
Total serum bilirubin 20 mg%, direct Coombs test (DCT) –ve, sepsis screen negative, peripheral smear showed no abnormality, retic count 2%.
Severe pathologic indirect hyperbilirubinemia of multifactorial etiology.
This newborn delivered in hospital and seen by a pediatrician ended up with severe jaundice as systematic evaluation of jaundice was not done. Neonatal jaundice estimation is clinical and risk factor based.
All newborns should be examined for jaundice at every opportunity, especially in the first 72 hours. Jaundice is assessed by inspecting the baby's skin, sclera or mucous membranes preferably in natural light. The skin is blanched by digital pressure over bony parts to reveal underlying yellowing. It must be realized that visual examination is not reliable especially in dark pigmented babies, preterms and in babies receiving phototherapy.
Breastfeeding insufficiency predisposes to development of jaundice. It should be suspected if there is a delay in the elimination of meconium, fewer than three evacuations per day, and presence of meconial feces on the third or fourth postnatal day, decreased urinary flow, or weight loss greater than 5–7% on the third day after birth. Decreased caloric intake, inhibition of hepatic excretion of bilirubin and an increase in intestinal absorption of bilirubin (enterohepatic circulation) are suggested mechanisms for the hyperbilirubinemia associated with breastfeeding.
This case had many of these risk factors which predisposed to developing significant jaundice, e.g. late preterm, low birth weight (LBW), primigravida, weight loss and jaundice requiring treatment in elder sibling.10
Table 1   Pre-discharge checklist for jaundice
Risk factors
Tick here
• Primipara mother
• Visible jaundice at discharge
• Gestation < 38 weeks
• History of jaundice requiring treatment in previous sibling
• ABO/Rh incompatibility
• Geographic prevalence for G6PD deficiency
• Weight loss at discharge >3% per day or >7% cumulative weight loss
Notes: 1. Newborns with risk factors should be seen within 24–48 hours of discharge.
2. More the risk factors present more is the chance of developing severe jaundice.
Source: Adapted from NNF Clinical Practice Guidelines, 2010.
Risk factors are often overlooked and opportunity for timely intervention to prevent severe jaundice is missed. Table 1 lists the Pre-discharge checklist for jaundice. One should do transcutaneous or serum bilirubin in a baby with risk factors seen on D3-D4.
All babies with jaundice should have evaluation for breastfeeding adequacy.
All newborns should be assessed for presence of risk factors for jaundice at the time of discharge. Relying only on clinical estimation of jaundice is misleading.
Male baby of 48 hours old (2.4 kg) was brought with yellowishness by parents. Baby was delivered at 34–36 weeks of gestation to primigravida by spontaneous, uneventful vaginal delivery. Baby was discharged by 12 hours from hospital, given Bacillus Calmette-Guerin vaccine/oral polio vaccine (BCG/OPV) and breastfed.
Baby was near term, alert, active, stable vital parameters with jaundice up to trunks. There was no pallor, plethora, rash, cephalhematoma or foul discharge. There was no organomegaly, high colored urine and no significant weight loss. Breastfeeding appeared to be well. On parent's insistence total serum bilirubin was done which came 9 mg% (48 hour age). Parents were assured and asked to follow-up for vaccination. After 48 hours, the baby was brought with poor feeding and noticed to have jaundice up to soles with opisthotonus posturing and shrill cry. Moro's was sluggish.11
Baby blood group was A +ve, mother O +ve, hemoglobin (Hb) 15 mg%, counts within normal limits, TSB −22 mg%, Retic count −4%, DCT negative, peripheral smear showed no abnormality.
In view of bilirubin encephalopathy, urgent double volume exchange transfusion was done and intensive phototherapy continued. Trend in fall of bilirubin was noted. Tone cry and activity improved by day 3.
Bilirubin encephalopathy secondary to ABO blood group incompatibility in near term and LBW.
All health care providers should be vigilant about jaundice in first week of life. Clinical evaluation of jaundice is misleading and when in doubt serum bilirubin should be estimated. This newborn had no maternal blood group known, was interpreted in bilirubin value (9 mg%) in isolation, bilirubin was not interpreted looking at age in hours and the interpretation did not look at risk factors (near term, primigravida, ABO incompatibility).
Analyzing the baby as per American Academy of Pediatrics (AAP) Guidelines for Neonatal Hyperbilirubinemia (Table 2), at 48 hours the baby was in high-risk group with bilirubin in phototherapy range was ignored. In setting of ABO incompatibility and prematurity the jaundice increased significantly leading to bilirubin encephalopathy which was despite having seen by pediatrician in a hospital delivery which was essentially preventable.
  • Do not rely on bilirubin value alone in evaluating baby with jaundice. Interpret bilirubin in relation to risk factors. Jaundice is usually multifactorial.
  • Interpret bilirubin levels according to the infant's age in hours and not by its value.
Table 2   Total serum bilirubin levels (mg/dL)
Low risk
Medium risk
High risk
≥ 38 week and well
≥ 38 week + risk factors* or 35–37 6/7 week and well
35–37 6/7 week + risk factors*
Age (hours)
Intensive PT
Intensive PT
Intensive PT
Source: Adapted from AAP guidelines.
*Risk factors—isoimmune hemolytic disease; G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis or albumin <3.0 g/dL. Abbreviations: PT–phototherapy; ET–exchange transfusion.
  • Jaundice is a preventable and treatable cause of mental retardation.
  • Use AAP charts for jaundice management (after 24 hours in >35 weeks of gestation).
A 22-day-old baby was brought to pediatrician with yellow appearance and yellow urine. Baby was referred as possible biliary atresia, and a poor prognosis and need for surgery was explained to family by the referring doctor. Baby was admitted and investigated for curable causes of cholestatic jaundice. Apart from cholestasis there were no organomegaly, dysmorphism, bleeding diathesis, rash, pallor, external anomaly or clay stools. Baby's bilirubin values were total 22 and direct 12 mg/dL. Blood and urine culture were sent. Liver enzymes, paired sera of IgG for toxoplasma, cytomegalovirus (CMV) were planned. Thyroid test, venereal disease research laboratory test (VDRL) and ultrasonography (USG) of abdomen were normal. Fundus revealed no chorioretinitis.
Baby's blood and urine culture grew Klebsiella sensitive to Meropenem [baby had no history of fever and c-reactive protein (CRP) was borderline 12 mg/dL]. Baby was started on Meropenem after a lumbar puncture was performed. Cerebrospinal fluid (CSF) examination was not suggestive of meningitis. Baby was treated with antibiotics for 14 days. The cholestatic jaundice improved and baby was discharged healthy.
Prolonged jaundice—urinary tract infection.
Neonatal jaundice—prolonged.
  • Ultrasound biliary tract—look for gallbladder (absence is suggestive of atresia or dilated biliary tree is suggestive of atresia)
  • Blood and urine culture
  • Urine reducing substances (Benedict's method positive and uristix negative) for galactosemia
  • Thyroid function test
  • VDRL for syphilis
  • Liver function test
  • CMV and toxoplasmosis.
Cholestatic jaundice and prolonged jaundice are emergencies. Biliary atresia must be diagnosed and operated early preferably by one month of life. Investigations must be directed to curable conditions.13
Bacteremia/sepsis may be present even in absence of overt clinical signs like fever/lethargy.
Always exclude occult sepsis as a cause of prolonged jaundice (especially if weight gain is poor).
Rh positive baby was delivered to an isoimmunized Rh negative mother. The previous baby had jaundice requiring exchange transfusion and mother was found to be indirect Coombs test (ICT) positive and baby DCT positive. The index baby was investigated at birth. The bilirubin was 5 mg/dL and Hb 11 gm/dL and DCT was positive. Baby was started on intense phototherapy. Baby's bilirubin and hemoglobin were repeated after 3 hours. The bilirubin rapidly increased to 10 mg/dL and Hb dropped to 8.5 gm/dL. Baby was started on IVIG 500 mg/kg over 4 hours. Rh negative blood was arranged for exchange, if the bilirubin would keep rising in spite of IVIG. Parents were informed that IVIG is a blood product, expensive, has the potential to decrease need for exchange transfusion and phototherapy.
Baby's bilirubin did not rise higher than 17 mg/dL and drop in Hb was noted to 8 gm/dL. Baby required phototherapy for 6 days. After 3 weeks, baby was followed up. Hemoglobin dropped to 6.8 mg/dL and baby required a top up transfusion. Family was advised to avoid live vaccines, oral polio drops and take inactivated poliovirus vaccine (IPV) instead, as live vaccines may be ‘neutralized’ by immunoglobulins transfused.
IVIG for Rh/ABO isoimmunization.
Intravenous immunoglobulin is an option to be used when serum bilirubin is rising despite intensive phototherapy or the value is within the exchange transfusion range in antibody mediated hemolysis (Rh, ABO) settings. The benefits include decreased need for exchange transfusion, duration of phototherapy and hospital stay in infants with hemolytic disease. It is postulated to block the receptors (Fc receptors) in the reticuloendothelial system that bind to the antibodies that cause cell death and hemolysis. Late anemia requiring blood transfusion is not uncommon in incompatibility settings. Parents must be educated regarding modifications of vaccines.
Monitoring of bilirubin is frequently required in jaundice of early onset (<36 hour). In settings where exchange transfusions is being contemplated or cannot be performed, IVIG is a useful therapy.14
Intravenous immunoglobulin reduces the need for exchange transfusion in ABO/Rh settings of incompatibility.
Healthy born baby had few episodes of vomiting after discharge to home. Baby was found to be well and family reassured and sent home. Baby was admitted at parent request on the next day. Baby appeared well except a suspicious history of bilious vomiting and intermittent fussiness and tachycardia up to 180/minute. The unit presumed this to be due to the baby being hungry, as there was no abdominal distention and baby had passed stools. X-ray of abdomen was ‘normal’ and surgeon advised a stomach wash and planned a barium study next morning if vomiting persisted.
At night, the baby's abdomen progressively got distended, baby had persistent tachycardia and an episode of bile stained vomiting. Arterial blood gas (ABG) showed severe metabolic acidosis, antibiotics were changed, ductus dependant lesions of heart or in born errors suspected. Echocardiography (ECHO) was normal and screening tests for inborn error of metabolism (IEM): blood and urine were sent. The USG abdomen gave a clue to malrotation and the baby rushed for surgery and found to have malrotation of bowel and volvulus. Baby recovered thereafter.
Malrotation of Gut
Differential diagnosis of a baby with acute deterioration in health with abdominal distention can be sepsis, shock due to ductus dependant lesion, etc. High order of suspicion and an early barium study may clinch the diagnosis. In our case, barium study was delayed.
The normal position of the duodenojejunal junction is to the left side of the left pedicles of the vertebral bodies at the level of duodenal bulb in the frontal view and posterior placed (retroperitoneal) on the lateral view.
Plain X-ray may show intestinal obstruction.
Ultrasound can show abnormal direction of superior mesenteric vessels.
Malrotation of gut is a developmental abnormality, the gut fails to rotate and the duodonojejunal junction which should go behind the superior mesenteric vessels remains anterior and is attached with a narrow pedicle on which it can twist and lose blood supply. Early surgery, release of the abnormal connection can save a life and the child has a normal life thereafter.
If a parent says vomiting is significant or persistent (suspected bile), detailed examination, observation for clinical signs, and even a barium study is indicated.15
Bilious vomiting with non-distended abdomen is malrotation unless proved otherwise. Barium study is extremely helpful in diagnosis of malrotation—a life threatening emergency with limited clinical clues.
A healthy boy baby started having frequent vomiting on day 20 of life. Family was reassured that this is normal. Parents visited another doctor who treated with domperidone suspension considering parent anxiety and explained as gastroesophageal reflux disease (GERD). Symptoms were persisting; they were referred to a surgeon. Ultrasound abdomen was performed for hypertrophic pyloric stenosis and barium study for possible obstruction; they were not suggestive of any surgical condition. The baby landed in the emergency room 10 days later with severe lethargy, referred as inborn error of metabolism (IEM). Baby appeared dehydrated, had deep breathing, had lost 800 grams weight, but still passed plenty of urine in the hospital. X-ray showed a small appearing heart.
A clinical diagnosis of congenital adrenal hyperplasia (CAH) was suspected based on severe dehydration (in the absence of diarrhea or vomiting sufficient to cause such severe weight loss), acidotic breathing and drowsiness. Examination of genital area showed hyperpigmentation. Baby's serum sodium was 112 and potassium was 8. Blood sugar was 60 and blood pressure was normal. Baby was resuscitated with normal saline and started on hydrocortisone and fludrocortisone for very low sodium. Fluid free of potassium was ensured and potassium binding resin for severe hyperkalemia was started. In 2 days, the baby gained 400 grams weight, the sodium returned to 130 and the potassium normalized. Baby's vomiting stopped. Baby was discharged after 10 days on maintenance doses of hydrocortisone and fludrocortisone and oral saline and a ‘crisis card’.
Congenital adrenal hyperplasia.
Differential diagnosis of vomiting and weight loss in neonate:
  • Hypertrophic pyloric stenosis
  • Occult infections—urinary tract
  • Inborn errors of metabolism
  • Gastroesophageal reflux disease.
The combination of low sodium and high potassium is characteristic of adrenal insufficiency. Ultrasound abdomen showed normal urinary tract and prominent adrenals.
Occasionally this combination may be due to pseudohyperaldosteronism (end organ resistance) and obstructive uropathy.16
Congenital adrenal hyperplasia is not an uncommon condition. The commonest form is due to 21 beta-hydroxylase enzyme deficiency resulting in decreased production of cortisol and aldosterone (Flow chart 1).
Inheritance is autosomal recessive (consanguineous marriage).
Neonatal screening can identify the condition in a presymptomatic stage. CAH can cause sudden death due to severe hyperkalemia, can present like the index case with polyuria, weight loss, hyponatremia and hyperkalemia. Associated hypoglycemia and hypotension may also be present. Affected girls may have severely virilized genitalia (all the steroid precursors are channelized to testosterone) and present as ambiguous genitalia at birth.
Early diagnosis is life saving, and long-term outcomes are excellent.
Isolated vomiting is likely to be pathological and poor weight gain should be investigated.
zoom view
Flow chart 1: Deficiency of 21 beta-hydroxylase resulting in congenital adrenal hyperplasia
Simple lab tests—sodium, potassium must be a part of investigation of vomiting and weight loss. Hyponatremia and hyperkalemia is due to adrenal insufficiency most often.
A day 5 boy is brought for vaccination to OPD. He is well with no complaints. He was born to primigravida, with uneventful delivery and pregnancy. During routine auscultation you notice a single S2. No blood pressure gradient is evident between the upper and the lower extremities. Oxygen saturation in room air is 98% in the left upper extremity and 85% in the left lower extremity. Cardiovascular examination reveals a no appreciable murmur. The abdomen is soft, non-tender, and non-distended. The liver is palpable 2 cm. Lungs are clear and no retractions are noted. Other findings of the examination are within normal parameters. He is admitted to nursery.
A chest radiograph shows clear lung markings and a normal cardiac silhouette. Sepsis screen, electrolytes and glucose study are normal. A hyperoxia test reveals a PaO2 of 150 mm Hg. Echocardiography demonstrates transposition of great vessels. He is shifted to cardiac center for correction.
Transposition of great vessels with pulmonary hypertension.
Differential cyanosis (decreased saturations of the lower extremities compared with the upper extremities) is a common presentation of persistent fetal circulation with pulmonary hypertension of the newborn. Normally the transition from fetal to adult circulation sets in by 48 hours. At times the pulmonary pressures persist to be elevated than the systemic pressures leading to persistent pulmonary hypertension of the newborn (PPHN). This could be primary due to abnormality in pulmonary vasculature or secondary to underlying lung, heart or systemic illness. The split in S2 parallels the transition from fetal to adult circulation.
Absence of S2 split, split of S2 within first 24 hours or loud S2 is abnormal and suggests underlying heart defect.
The hyperoxia test could not rule out cardiac disease because it needs to be higher than 150 mm Hg, so additional studies need to be performed. Its value is to rule out cardiac disease, not rule it in.
Ascertaining the splitting of S2 is a clinical skill that takes patience and astute skills.
The assessment of second heart sound in newborns is one of the most accurate physical examination findings in children who have congenital heart defects.18
A 6 hour, term (2 kg) newborn is admitted for persistent irritability. He was born to primigravida, vaginally but needed 1 minute of bag and mask support to establish breathing. In view of good weight and activity, the baby was shifted to the mother. Breastfeeding was attempted but was not satisfactory. Baby had passed urine and stool but was crying excessively.
On examination, the baby appears jittery. The movements persist despite attempt to restrain them. There are cyclic movements of limbs and starring of eyes. There is no evidence of birth injury, pallor, plethora, rash, meconium staining or foul smell. Heart rate (HR) was 160/min, respiratory rate (RR) 50/min with episodes of hyperventilation, T 36.5 C, cardiac resynchronization therapy (CRT) 2 second and mean noninvasive blood pressure (NIBP) 45.
Supportive care, oxygen and monitoring were initiated. Sepsis screen was sent. In view of persistent jitteriness and need for ventilation at birth, seizures secondary to perinatal hypoxic insult was thought of and loading dose of phenobarbitone (20 mg/kg) given. Seizures persisted for another 2 hours requiring loading dose of phenytoin. At this stage a B sugar done by glucostix was 15 mg%. A bolus of 2 mL/kg of 10% D was given and glucose infusion rate (GIR) calculated and infused. Sugar check after 30 minutes showed value of 45 mg%. Seizures stopped. Sugar check every 4 hours was continued for another 24 hours which was found to be normoglycemic. GIR was tapered and tube feeds introduced. By day 7, baby was breastfeeding, alert, active with no neuro deficit. Anticonvulsants were stopped at discharge.
Neonatal seizures due to transient symptomatic hypoglycemia in a small for gestational age (SGA) secondary to inadequate feeding with mild perinatal asphyxia.
The low glucostix value was confirmed by blood sugar in lab. Sepsis screen and blood culture were negative. S calcium was normal.
Neonatal hypoglycemia (B glucose < 40 mg%) is the most common metabolic disorder in newborn. Hypoglycemia may be symptomatic or asymptomatic. The presentation is non-specific and it may be associated with other disorders like asphyxia, sepsis, polycythemia, meningitis, etc. LBW infants, SGA, preterms, infant of diabetic mother and all sick newborns are ‘at risk’ for developing hypoglycemia.
All ‘at risk’ newborns must have a regular screening for blood sugar at 2 hours postnataly. Hypoglycemia to cause seizures is a ‘missed opportunity’ as seizure occurs late with hypoglycemia.19
zoom view
Fig. 8: Glucose rate calculator
The goal should be to screen and detect during asymptomatic phase. The seizures may respond transiently to anticonvulsants giving a false security to recur again.
Treatment should not be delayed while one is awaiting confirmation of hypoglycemia by lab analysis. Blood sugar less than 20 mg% or symptomatic hypoglycemic newborns need intravenous correction. Blood sugar 20−45 mg% in asymptomatic newborn may respond to trial of feed with recheck sugar 1 hour later.
Hypoglycemic newborns are at risk of adverse neurologic sequelae.
Glucose infusion rate (mg/kg/min) is calculated from fluid requirement (mL/kg/day) and the percentage of dextrose (Fig. 8). For example, at 60 c/kg/d of fluids using 10% dextrose will give a GIR of 4 mg/kg/min. The fluid requirement of dextrose percentage may be changed to alter the GIR.
There is no pathognomonic sign or symptom of hypoglycemia. All sick newborns and ‘at risk’ newborns must be monitored for blood sugar.
A 30-day-girl (3.4 kg) was presented with noisy breathing, breathing and feeding difficulty noted since last 12 hours. Mother noticed bluish lips while feeding for the first time. She was born at term following uneventful pregnancy, delivery and was exclusively breastfed. There were no concerns so far.20
She appeared well grown. Temperature: 36.8°C, Respiration: 40/min, Pulse: 130/min and Oxygen saturation: 95% in air. There was stuffy nose with rhinorrhea. No increased work of breathing. Conducted sounds were heard on auscultation of the chest. Pulses and heart sounds were normal.
As she was not feeding well, a nasogastric tube was inserted and its position was confirmed. Over next few minutes the baby was found to have froth at mouth, gurgling, severe respiratory distress and cyanosis. The nurse called for help and did a quick suction and removed the feeding tube. By the time the doctor arrived the baby was crying vigorously, her color was pink and she had no respiratory distress.
The other nostril did not admit a 6 Fr nasogastric tube which clinched the diagnosis.
The computer tomographic (CT) scan with 3 mm transverse sections is the preferred method to confirm a diagnosis of unilateral or bilateral choanal atresia. The composition (membranous or bony) and thickness of the atresia are assessed. The depth of the nasopharynx and any associated skull base anomalies are detected.
Apparently well grown with bluishness on feeding, with exacerbation following insertion of nasogastric tube with immediate relief with suction and immediate tube removal suggests a local structural cause leading to partial obstruction of upper airway, choanal atresia, nasal septal deformity, nasal foreign body or choanal polyp.
Newborns are obligate nose breathers; in this baby the nasogastric tube was blocking the only patent airway. When suction was done and the tube removed, the baby cried and the airway became patent again resulting in the resolution of cyanosis and respiratory distress.
Inability to insert nasogastric tube suggests the diagnosis of choanal atresia. Misting on to a cold spoon showed no misting from the other side nostril.
CT scan confirmed unilateral membranous choanal atresia. Parents were explained the nature and course of illness and how to keep airway patent by suction, positioning, normal saline nasal drops and taught basic cardiopulmonary resuscitation (CPR). Periodic visits were advised.
Choanal atresia is a congenital anomaly of the anterior skull base characterized by closure of one or both posterior nasal cavities. Approximately 60% of reported cases are unilateral. Unlike bilateral atresia, most unilateral cases are isolated anomalies.
Unilateral lesions can often go undiagnosed for long periods. When bilateral, choanal atresia manifests early with respiratory distress and needs immediate airway support. Unilateral lesions have persistent unilateral nasal drainage. Occasionally patients develop obstructive sleep apnea during infancy if the non-atretic side is not sufficiently patent. Careful questioning reveals an unusual susceptibility to upper respiratory symptoms. Parents often report elaborate rituals of pulling strands of mucus from their child's nose. Failure to pass a catheter through the occluded nostril can be misleading in the older child because there is enough space in the nasal cavity for the catheter to curl without passing into the nasopharynx.21
In cases where the skull base has a relatively normal shape and there are no cardiac contraindications to general anesthesia, bilateral choanal atresia is repaired shortly after birth. If there is associated obstructive sleep apnea, failure to thrive or respiratory distress, an early repair of a unilateral lesion may be indicated. Repair for unilateral lesion at around 2–3 years of age is generally accepted.
Bluishness exacerbated by crying suggests cyanotic heart disease. Bluishness relieved on crying suggests choanal atresia.
Persistent unilateral nasal discharge or unusual susceptibility to upper respiratory symptoms should raise suspicion of underlying upper airway abnormality (e.g. choanal atresia).
A 6-day-girl presented with history of poor feeding and episodes of bluishness of lips, fingers and toes since last few hours. She was born at full-term by spontaneous vaginal delivery following an uncomplicated pregnancy with a birth weight of 2.8 kg. She was discharged home on the second day of life, and has been breastfeeding well.
On examination she is pale and lethargic. Her weight is 3 kg, and she is tachypneic, has subcostal-intercostal indrawing with a respiratory rate of 80 breaths/min. Her heart rate is 180 beats/min and her capillary refill time is 5 seconds. Blood pressure (BP) was not appreciable in lower limb. Femoral pulses were not palpable. There is no murmur. She has a liver palpable to 4 cm below the costal angle. There is no dysmorphism or external congenital anomaly.
Arterial blood gas showed metabolic acidosis with respiratory compensation. X-ray contrast media (XRC) showed mild cardiomegaly. 2D echocardiography confirmed the diagnosis of coarctation of aorta.
Abrupt deterioration in a well-baby is most commonly seen due to heart diseases like ductus dependant heart disease, hypoplastic left heart syndrome, transposition of great vessels or an arrhythmia. Features of weight gain, absent femorals with signs of congestive cardiac failure suggest coarctation of aorta. The baby was stabilized and prostaglandin infusion started to keep ductus patent. Surgical correction was done.22
Coarctation of aorta is the most frequently missed congenital heart defect. Many cases are not diagnosed till adulthood or death and frequently are mislabeled due to sepsis.
In the neonatal period it remains asymptomatic till ductus closes. Thereafter it presents with an acute onset of obstruction to systemic blood flow, leading to left ventricular failure and cardiovascular collapse. A patent ductus arteriosus (PDA) allows blood to pass from the right ventricle to the descending aorta, and when the PDA closes, this leads to acute cardiovascular collapse. It may manifest with breathlessness, feeding difficulty, failure to thrive, hypertension (upper limb to lower limb systolic BP > 20 mm Hg) or with signs of cardiac failure with half of the cases presenting between days 5–14.
Treatment of hypertension in children requires use of angiotensin-converting-enzyme (ACE) inhibitors, B blockers or angiotensin receptor blockers. Long-term follow-up post-surgery is mandatory because of risk of hypertension and aneurysm formation.
All newborns should have femoral pulse check before hospital discharge.
All babies with suspected heart disease should have BP measurement in upper and lower limb.
You are asked to interpret the sepsis screen done on admission.
Total leukocyte count (TLC)
Platelet (L)
Absolute neutrophil count (ANC)
Immature to mature ratio (I:T)
5 mg/dL
Most commonly used components of sepsis screen are total leukocyte count (TLC), absolute neutrophil count (ANC), I:T ratio, CRP and erythrocyte sedimentation rate (µESR). A sepsis screen is considered positive if two or more of the parameters are abnormal. (Sensitivity 93–100%, specificity 83%, positive and negative predictive values of 27% and 100%). Sepsis screen does not include blood culture, chest X-ray or lumbar puncture—these are definitive tests.23
Case 1
The screen is negative. In case of maternal risk factors for sepsis like premature rupture of membranes (PROM) more than 12 hours, preterm birth with pre-labor rupture of membranes, antibiotic treatment given to the mother for confirmed or suspected invasive bacterial infection 24 hours before birth, during labor or within 24 hours after the birth and suspected or confirmed chorioamnionitis one should consider the gestation for deciding the further plan of action. One may opt for observing a term baby who is asymptomatic with screen negative in presence of risk factors, but in case of preterm with risk factors one would start treatment even if asymptomatic and screen are negative.
A sepsis screen on admission has a positive predictive value of only 40%, i.e. 60% of subsequently proven babies with infection will have a negative sepsis screen on admission. Hence timing of the sepsis screen is essential while interpreting. A negative sepsis screen on admission does not rule out sepsis as it takes at least 12–24 hours for changes to be reflected in blood following onset of infection.
Case 2
An elevated white blood cells (WBC) count is a non-specific marker. With automated machines, inclusion of nucleated red blood cells (RBC) may falsely elevate the WBC count. An elevated WBC count may occur with any stress to the marrow like maternal fever, difficult or prolonged labor, perinatal asphyxia, meconium aspiration, pneumothorax, intraventricular hemorrhage, hemolysis or seizures. In all such conditions the count resolves by 48–72 hours. There is no need to start antibiotics in such conditions.
Case 3
Subclinical thrombocytopenia needs to be differentiated from pseudothrombocytopenia. A peripheral smear will show platelet clumps in pseudothrombocytopenia while in true conditions the platelets will be depleted on smear. One needs to look at the trend and clinical status while interpreting platelets. One would repeat the counts after 48–72 hours, or if baby shows signs of bleeding. Early onset thrombocytopenia (<48 hours) is usually non-infective in origin. Thrombocytopenia occurs late in sepsis evolution and suggests severe infection. Hence interpret thrombocytopenia with clinical status and treat the baby not the numbers.
Case 4
A sick newborn with negative sepsis screen. All sick newborn babies (term and preterm) need sepsis evaluation and treatment for infection regardless of the presence or absence of risk factors and status of sepsis screen. A negative sepsis screen in a symptomatic baby does not take away the diagnosis of infection and would merit initiation of treatment. A repeat negative sepsis screen after 48 hours in a symptomatic baby almost rules out a bacterial infection.
The utility of sepsis screen is maximum when there is clinical ambiguity, i.e. you are not sure whether to give antibiotics or not, e.g. decreased activity with some gastric aspirates, and baby appears stable—in this situation, if screen is negative, you should withhold antibiotics; if positive; you will give antibiotics. On the other hand, if in your clinical judgment, you feel antibiotics have to be started, e.g. sick baby (sclerema) screen serves no purpose, do a blood culture and start antibiotics.24
Case 5
Well baby with negative sepsis screen. A +ve CRP is a non-specific marker. CRP may rise in non-infective inflammatory conditions (asphyxia, meconium aspiration, etc.) thus mimicking bacterial infection. Quantitative estimation of CRP > 10 mg/L) is more important than qualitative estimation (i.e. CRP +ve or –ve). The most accurate, rapid and reliable measurement of CRP is by nephelometry. Sensitivity of the CRP test at presentation is only 40%, i.e. 60% of subsequently proven sepsis episodes will have a normal initial CRP. The positive predictive value for a raised CRP is poor so a positive test is poorly predictive of sepsis.
  • Interpret sepsis screen taking into consideration the risk factors, gestation of infant, clinical status, timing of the screen and culture report.
  • Taken in isolation none of the tests are definite indicators of sepsis. A number of non-infectious conditions can cause abnormality misleading to diagnosis of sepsis and antibiotics initiated.
  • Sepsis screen is good in ‘ruling out’ sepsis rather than ‘ruling in’ sepsis. Do not use sepsis screen to decide duration of antibiotics. Treat the baby/bacteria and not the screen.
  • Do not use sepsis screen as a substitute for blood culture.
  • When a clinician is faced with an infant with a possible serious infection, treatment may be started with antibiotics immediately. Clearly the test result will not affect the decision to start treatment if there is already strong evidence of the infection.
Similarly, in the absence of indications of infection, the clinician may not start treatment even if the test was positive. The test is most likely to be useful when the case history and the condition of the patient leave the clinician in serious doubt about the presence of infection, in which case the diagnostic test may be used as a decision rule; start treatment if the test is positive; delay treatment if the test result is negative.
A 10-day-boy, 36 weeks gestational age (2.2 kg) presente with fever. He was discharged 4 days back from neonatal intensive care unit (NICU). He was born to primigravida, admitted for respiratory distress from birth requiring oxygen for 24 hours and treated for jaundice for 3 days. He received cefotaxime and amikacin for 5 days in view of clinical sepsis. His blood culture was not done. He was neurologically well except for one episode of subtle seizure but with no recurrence thereafter. He had started to feed well on breast at the time of discharge. Mother noted irritability since last 12 hours and decreased feeding. There were abnormal movements of eyes and face noted by mother over last one hour.
His temperature on admission was 38°C, with no core axillary mismatch with RR 55/min, HR 160/min, CRT 2 sec, well pulses well felt. There were subtle seizures. There was no pallor, rash, icterus, sclerema, bleeding from any site or foul discharge. He was stabilized on supportive care.25
Total leukocyte count 28,000/cumm, Hb 15 gm%, platelets 1.25 L, with 65% segmented and 2% band forms. CSF study showed 850 WBCs, protein of 137 mg/dL and glucose of 20 mg/dL. No bacteria were seen on the smear. A blood culture isolated acinetobacter. CT brain study showed no evidence of abscess.
Acinetobacter sepsis with pyogenic meningitis.
The antibiotics were changed as per sensitivity and given for 3 weeks.
This near term symptomatic infant was treated for clinical sepsis at birth but without a blood culture. An episode of subtle seizures was ignored and not evaluated. In view of clinical response to antibiotics often a CSF study is not done. CSF study is also ignored neurologic manifestations are not predominant. This leads to partial treatment of meningitis and predisposes to risk of complications like abscess. The danger of missing the diagnosis of meningitis is difference in treatment and outcome as it merits change in the dose, duration and prognosis.
Certain gram-negative bacteria have a predilection for causing brain abscess, including Acinetobacter, Citrobacter, Enterobacter, Salmonella, Serratia, Proteus, and Pseudomonas species. Presence of these organisms should warrant a neuroimaging study to rule out abscess.
  • Treating with antibiotics without blood culture can miss or partially treat meningitis with disastrous consequences.
  • CSF study should be done for all newborns who are sick, are suspected to have meningitis, positive sepsis screen, positive blood culture and as part of evaluation for late onset sepsis irrespective of neurologic signs or symptoms.
A preterm baby, 30 weeks (1,250 gram) at birth was ventilated for respiratory distress syndrome (RDS) and received cefotaxime amikacin for 1 week for suspected infection. Baby received amino acids and lipids for 1 week as the feeds were being escalated. After 2 weeks the baby developed apnea and abdominal distension and was investigated. The CRP was very high 120 mg/L and platelet count was only 6,000. Baby was started on meropenem and blood culture was sent. After 48 hours lab reported Candida species in blood culture.26
Baby was started on liposomal amphotericin and antibiotics were stopped. The baby improved in the week that followed, but, required three platelet transfusions in first 3 days. Culture drawn on 3rd day of amphotericin was sterile. Baby was continued on 14 days of amphotericin after this.
Figure 9 shows fungal hyphae.
Fungal sepsis.
Urine microscopy for fungal hyphae (Fig. 9) and budding yeasts; fundus examination may also show fungal balls. Ultrasonography kidney-ureter-bladder (USG KUB) may show mycetoma (fungal balls) in renal pelvis. CSF examination is also important to rule out fungal meningitis.
In very preterm babies, even short duration of broad spectrum antibiotics, central catheters, parenteral nutrition, steroids, peritoneal or renal procedures can predispose to fungal sepsis. High index of suspicion is required as clinical symptoms and signs may be non-specific. Fungal infections are not uncommon; they are usually not suspected or properly investigated. Clinicians often consider all elevated CRP as bacterial infection and escalate antibiotics.
Fungi can best grow in immunocompromised host on broad spectrum antibiotics, with bacteria cleared. These infections can present like sepsis, pneumonia, abdominal distension, obstructive anuria, skin rash and refractory thrombocytopenia. One must consider possibility of fungal infections in babies not improving on a broad spectrum antibiotic.
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Fig. 9: Fungal hyphae
Survival of babies with fungal infection depends on the early diagnosis and treatment. Amphotericin is the antifungal drug of choice for empiric therapy. It must be administered for at least 2 weeks after cultures are sterile.
Fungemia should be considered in all babies with more than 7 days antibiotics with unexplained deterioration. One must limit the use of broad spectrum antibiotics in very preterm babies.
High CRP, low platelet count, abdominal signs and insidious illness with more than 7 days antibiotics warrant ruling out fungal sepsis.
A 5-day-old baby was referred for poor suck at breast and poor cry. Baby was otherwise well appearing and infection screens, electrolytes and thyroid functions were normal. Baby-mother dyad was helped by lactation team for a day. Lactation nurse also felt baby goes to sleep easily. Baby was observed in NICU. The baby was found to desaturate intermittently very briefly to 65%. Repeat labs were normal. Baby was started on antibiotics in spite of negative sepsis tests. No improvement was noted in 5 days. Parents were informed about need for investigation. CSF examination, MRI and metabolic screen were performed.
MRI diffusion weighted imaging (DWI) showed a well-defined infarct in the middle cerebral artery distribution on left side (Fig. 10). The T1 and T2 images of MRI were uncharacteristic. CSF examination and newborn screen report were normal.
Figure 10 shows MRI diffusion weighted images showing a well-defined infract in the distribution of middle cerebral artery on the left side.
Neonatal stroke.
Investigations for cause of stroke, like ECHO, studies for prothrombotic conditions, etc., can be planned later.
Neonatal stroke is probably more common than in adult/geriatric age! Neonates are predisposed to thrombosis because of physiological tilt in balance between thrombotic and thrombolytic mechanisms.28
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Fig. 10: MRI diffusion weighted images
Hypoxic ischemic encephalopathy (HIE), birth trauma, vascular malformations, infections and inherited prothrombotic conditions have been associated with neonatal stroke. In the neonate signs of encephalopathy, poor alertness, poor suck, altered cry are often described by parents and most often not due to any underlying medical problem. Currently lack of awareness and non-specific nature of the condition are cause of under diagnosis. Diagnostic test is a diffusion weighted MRI that shows the stroke within a day or two of the insult. The result of stroke can be cerebral palsy, learning disabilities, etc. Some may recover without major neurological deficit.
Parent concern of poor suck, excessive sleepiness must be clinically assessed and if necessary evaluated with blood sugar, serum sodium, metabolic tests, CSF examination and MRI if baby is really lethargic and one must think beyond infections.
MRI is a useful investigation in encephalopathy of unexplained origin.
A day 3, boy (2.9 kg) was brought with profound bloody vomiting and rectal bleeding. He was exclusively breastfed with uneventful pregnancy and delivery. There was no family history of any illness and he was born of non-consanguineous marriage.29
He appears well, alert and active. While in hospital he has another episode of bleeding per oral. There is no bleeding from any other site, fever, foul discharge from any site, pustules, pallor, icterus, external congenital anomaly, petechiae, purpura, bruises, abnormal movements or dysmorphism. There is no organomegaly. Anterior fontanel (AF) is level. Neonatal reflexes are symmetrical.
On admission, Hb 15 gm%, TLC 8,000/cumm, platelets 2.25 L, liver function is normal, prothrombin time (PT) is 55 second and partial thromboplastin time (PTT) is 65 second.
He was administered intravenous (IV) vitamin K, 5 mg, followed by a fresh frozen plasma transfusion. A repeat PT/PTT 24 hours later showed normal values. His bleeding subsided. The Hb on admission was normal but in view of significant bleed a repeat Hb 8 hours later showed a drop needing a packed cell transfusion. There was no vitamin K administered at birth.
Well baby with spontaneous, localized, fresh bleeding with abnormal PT/PTT in presence of normal platelet count suggests vitamin K deficiency bleeding disorder (VKDB).
Newborn babies are at particular risk of vitamin K deficiency, as placental transfer is limited and human milk is a poor source. Normal adult concentrations of PT are not achieved until 6 months of age. In contrast, the activated PTT shows a similar pattern compared to adults through the first six months of life. A variation in these values therefore needs to be interpreted cautiously. VKDB leads to prolonged PT/PTT. But a prolonged PT/PTT is neither specific for, nor an early indicator of, vitamin K deficiency, because it may arise from a variety of conditions.
Early VKDB presents within 24 hours of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants (carbamazepine, phenytoin and barbiturates but not valproic acid), tuberculostatic (isoniazid, rifampicin), some antibiotics (cephalosporins) and vitamin K antagonists (coumarin, warfarin).
Classic VKDB (days 1–7) is prevented by administration of 1 mg vitamin K. In exclusively breastfed infants, single intramuscular (IM) administration at birth is also effectively preventing (rare) late VKDB but single oral administration is not.
Use of menadione or vitamin K3 has been abandoned as its use is associated with hemolytic anemia, indirect hyperbilirubinemia and kernicterus.
Protein induced by vitamin K absence/antagonist-II (PIVKA-II) is a functionally abnormal undercarboxylated form of prothrombin which is released into the serum in vitamin K deficiency states. PIVKA-II is normally undetectable (<0.02 ng/mL) in the serum of healthy subjects, whereas in overt vitamin K deficiency it circulates in high levels. Its serum concentration therefore provides a sensitive, functional indication of recent vitamin K status.
  • All newborns need vitamin K at birth.
  • A normal Hb on admission in a bleeding neonate may be falsely assuring but a repeat Hb 6–8 hours later reflects the true status.
Vitamin K deficiency bleeding disorder is under diagnosed and needs a high index of suspicion. It is a preventable cause of morbidity.
Term baby was admitted to hospital for poor feeding, abdominal distension on 10th day of life. Sepsis/necrotizing enterocolitis (NEC) were suspected. Baby's feeds were withheld and antibiotics started. Baby's condition did not improve. Baby's hands and feet remained cold in spite of inotropes, antibiotics and baby remained sleepy.
Baby was referred to a tertiary hospital, antibiotics changed and fluid and inotropes optimized. CSF examination was normal, infection tests were negative, primary screen for metabolic disorders—ammonia, pH and urine reducing substances were normal and MRI brain was normal. The unit protocol was followed and the nurse sent thyroid screen—thyroid-stimulating hormone (TSH) was reported as more than 100 by lab and free T4 was very low. A diagnosis of congenital hypothyroidism (CH) was made. In retrospect, every sign of the case was pointing to a possibility of CH.
Baby was started on 50 microgram of thyroxine orally. After 3 weeks baby was clinically normal, free T4 and TSH were normal. Dose of thyroxine was reduced to 25 microgram. One month later the dose could be reduced to 12.5 microgram (free T4 was in upper half limit of normal). The infant was monitored 3 monthly initially and then 6 monthly for growth, development and thyroid function. Parents were educated that medications must not be stopped before 3 years age, as brain growth is dependent on optimal thyroid function.
Congenital hypothyroidism. Differential diagnosis can vary depending on the dominant clinical signs. Although the constellation of CH symptoms and signs are typical, they may present only weeks later. In this case we found the open posterior fontanel and wider anterior fontanel after the thyroid function report was obtained!
Free T4, TSH, ultrasound neck and radionuclide to look for ectopic thyroid tissue.
Screening for congenital hypothyroidism is a routine in many nations for more than three decades. Although debates on cost effectiveness have continued, therapy is very economical (1–2 rupees per day) and outcome excellent if treatment is started in the first 2 weeks of life. Delay in treatment causes mental retardation.
Most common cause for congenital hypothyroidism is aplasia or absent thyroid gland. This results in permanent hypothyroidism. Some may be associated with ectopic thyroid tissue in 31tongue, other parts of mouth and neck. Accidental removal of the tissue will causes further loss of function.
Incorporate routine screening for congenital hypothyroidism in newborns. Selective testing for babies presenting with lethargy, delayed passage of meconium, wide fontanel and admitted to hospitals will have higher yield, but is likely to miss babies like in this case.
No clinical sign is pathognomonic of CH. Clinical diagnosis is not reliable for early detection. Congenital hypothyroidism is preventable and treatable cause of developmental retardation.
A male baby had a hemangioma swelling on upper eyelid (Fig. 11) that was increasing in size and causing difficulty in opening of the eye noticed since first month of life. At 4 months age, in view of functional impairment, it was decided to treat with propranolol.
Baby was started on propranolol, 1 mg/kg dose twice a day. Baby was monitored in hospital for 1 day for hypoglycemia, hypotension or excessive sleepiness. Within 3–4 days, there was a dramatic decrease in size of the hemangioma. Medication was continued for 6 months.
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Fig. 11: Hemangioma swelling on the upper eyelid
Vascular hemangiomas are the most common vascular tumors in children occurring in 5–10% infants. They are more common in preterm babies. Although they are mostly small, some can grow to disfiguring sizes, bleed or get infected. They rarely can involve airway, orbit and visceral organs. Mostly, they appear a few days after birth, grow rapidly in early infancy and slow down and involute by one year age. Most require no treatment, only parental education is required.
Propranolol is now considered as the first line therapy for large or multiple hemangiomas. Until recently, systemic steroids were preferred mode of therapy. But studies have shown propranolol to be more effective and have lesser side effects. Mechanism of action of propranolol is not clear, could be beta-adrenergic effect (changes in hemangioma may be seen within 24 hours as pallor and decrease in size on some occasions), downregulation of growth factors. Mostly safe, but, monitoring for bradycardia, hypotension, hypoglycemia and bronchospasm is necessary. Use of propranolol for children with simple hemangiomas, particularly for cosmetic reasons is not justified.
Steroids are associated with greater toxicity including more serious side effects such as stunted growth, hypertension and hypertropic obstructive cardiomyopathy, and today are no longer the preferred choice.
Propranolol therapy is more effective and safer for treatment of infantile hemangiomas than steroids or other existing modalities.
Hemangioma that is large, disfiguring or causing functional disturbance can be treated with propranolol with rapid and good effect.