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Ifthereareanyconcerns about sexual abuse, the child must be seen by a paediatrician(seeCh. Rarely,androgeninsensitivity syndrome (testicular feminisation) can present as a herniainaphenotypicfemalewhoactuallyhasamale genotype. In prolonged (persistent) neonatal jaundice, check if it is conjugated hyperbilirubinaemia, as this is due to liver disease. Hepatic dysfunction Encephalopathy Jaundice Epistaxis Varices with portal hypertension Spider naevi Muscle wasting from malnutrition Bruising and petechiae Splenomegaly with portal hypertension Hypersplenism Hepatorenal failure Liver palms Peripheral neuropathy Rickets secondary to vitamin D deficiency Clubbing Loss of fat stores secondary to malnutrition Neonatal liver disease Many newborn infants become clinically jaundiced. This is usually an unconjugated hyperbilrubinaemia, which resolves i spontaneously(Box20. There is an urgency to diagnose liver disease as early aspossibleintheneonatalperiod,becauseearlydiag nosisandmanagementimprovesprognosis. Babies with biliary atresiahaveanormalbirthweightbutfailtothriveas the disease progresses. They are usually mildly jaun dicedand,followingpassageofmeconium,theirstools are pale and their urine dark. Although stool colour mayfluctuate,palestoolsisanimportantabnormality and warrants investigation, even in the absence of clinical jaundice. Hepatomegaly is often present and splenomegaly will develop secondary to portal hypertension. Afastingabdominalultrasound may demonstrate a contracted or absent gallbladder, though it may be normal. Liver biopsy demonstrates features of extrahepatic biliaryobstruction,althoughfeaturesmayoverlapwith thoseofneonatalhepatitis,especiallyifcarriedoutat an early stage of the disease. The diagnosis is con firmed at laparotomy by operative cholangiography whichfailstooutlineanormalbiliarytree. Treatmentconsistsofsurgicalbypassofthefibrotic ducts, hepatoportoenterostomy (Kasai procedure), in which a loop of jejunum is anastomosed to the cut surfaceoftheportahepatis,facilitatingdrainageofbile fromanyremainingpatentductules. Ifsurgeryisper formed before the age of 60 days, 80% of children achieve bile drainage. Postoperativecomplicationsinclude cholangitis and malabsorption of fats and fatsoluble vitamins. Biliary atresia is the single most common indication for liver transplanta tioninthepaediatricagegroup. Choledochal cysts these are cystic dilatations of the extrahepatic biliary system. Intheolderagegroup,choledochalcystspresentwith abdominal pain, a palpable mass and jaundice or cholangitis. Treatmentisbysurgicalexci sionofthecystwiththeformationofaRouxenYanas tomosis to the biliary duct. Neonatal hepatitis syndrome In neonatal hepatitis syndrome, there is prolonged neonataljaundiceandhepaticinflammation. In contrast to biliary atresia, these infants mayhaveintrauterinegrowthrestrictionandhepato splenomegalyatbirth. There are many phenotypes of the protease inhibitor (Pi)whicharecodedonchromosome14. The majority of children who present with 1 antitrysindeficiencywilleitherhaveprolongedneona taljaundiceor,lesscommonly,bleedingduetovitamin K deficiency (haemorrhagic disease of the newborn). At 5 weeks of age, he pre sentedwithpoorfeedingandvomitingandahistory of bruising on his forehead and shoulders. In persistent neonatal jaundice, early diagnosis of biliary atresia improves the prognosis. Intrahepatic biliary hypoplasia Syndromic causes Alagillesyndromeisarareautosomaldominantcondi tionwithwidelyvaryingpenetrance. Infantsmayhave characteristic triangular facies, skeletal abnormalities, congenitalheartdisease(classicallyperipheralpulmo nary stenosis), renal tubular disorders, defects in the eye and intrahepatic biliary hypoplasia with severe pruritus and failure to thrive. Prognosis is variable, with 50% of children surviving into adult life without liver transplantation.

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In some cases (meaning refractory or relapsed disease), susceptibility testing of the C. Prevention Recommendations Preventing Exposure No strategies have been proven to prevent exposure. Serologic studies of immunocompetent children in an urban setting indicate that most children have been infected by C. Treatment Recommendations Treating Disease Note: these recommendations are largely based on high-quality evidence from studies in adults. Because of rapidly developing resistance, flucytosine alone should never be used to treat cryptococcosis. After completion of consolidation therapy, secondary prophylaxis (maintenance therapy or suppressive therapy) should be initiated (see below). Similar data describing experience with therapeutic lumbar punctures in children with cryptococcal meningitis are not available. Not specific to cryptococcal meningitis, a cutoff opening pressure of 28 cm of water has been proposed in children, above which the pressure should be considered elevated. Monitoring serial serum cryptococcal antigen titers is not useful for following treatment efficacy because changes in serum cryptococcal antigen titers do not correlate well with outcome during treatment for acute meningitis or during suppressive therapy. Monitoring for Adverse Events Adverse effects of amphotericin B (Table 5) are primarily nephrotoxicity; permanent nephrotoxicity is related to cumulative dose. Infusion-related fevers, chills, nausea, and vomiting can occur, but they are less frequent in children than in adults. Close monitoring for drug toxicities is needed especially when amphotericin B is used with flucytosine. Fluconazole and the other azoles have relatively low rates of toxicity, but their potential drug interactions can limit their use. Symptoms of meningitis are similar to those described for meningitis presenting as the initial manifestation of cryptococcosis. Although many cases resolve spontaneously, some experts also have used anti-inflammatory therapy. If cultures remain positive, evaluation of antifungal susceptibilities can be considered, although C. Patients in whom initial azole-based therapy fails should be switched to amphotericin B-based therapy,30 ideally in combination with flucytosine; the possibility of drug interactions resulting in sub-therapeutic azole levels (meaning concurrent rifampin use or other drugs metabolized by the liver) should be explored. A few patients with cryptococcal infections refractory or intolerant to standard antifungal therapy have been treated with posaconazole or voriconazole with variable success. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Extrapulmonary cryptococcosis in children with acquired immunodeficiency syndrome. Cryptococcus neoformans meningoencephalitis in African children with acquired immunodeficiency syndrome. Clinical and host differences between infections with the two varieties of Cryptococcus neoformans. Global trends in the antifungal susceptibility of Cryptococcus neoformans (1990 to 2004). A comparison of amphotericin B alone and combined with flucytosine in the treatment of cryptoccal meningitis. Treatment of cryptococcal meningitis associated with the acquired immunodeficiency syndrome. Dromer F, Mathoulin-Pelissier S, Launay O, Lortholary O, French Cryptococcosis Study G. Management of elevated intracranial pressure in patients with Cryptococcal meningitis. Cryptococcal immune reconstitution inflammatory syndrome: report of four cases in three patients and review of the literature. Risk factor analyses for immune reconstitution inflammatory syndrome in a randomized study of early vs. Voriconazole treatment for less-common, emerging, or refractory fungal infections. A placebo-controlled trial of maintenance therapy with fluconazole after treatment of cryptococcal meningitis in the acquired immunodeficiency syndrome.

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One scenario is to initiate the thiopurine at the time of the first course of corticosteroid, the second is after repeated courses of corticosteroids or in patients who are corticosteroid dependent. The most common scenario for maintenance of remission with a thiopurine is that of a corticosteroid-dependent patient. If steroid-free remission is maintained with parenteral methotrexate at 25 mg per week for 4 months, the dose of methotrexate may be lowered to 15 mg per week (204). It is perceived that patients with normal small bowel absorption may be started on or switched from parenteral to oral methotrexate at 15 mg to 25 mg once per week; however, controlled data evaluating this contention are lacking. The number of trials evaluated in the meta-analyses ranged from 7 to 10 with a total of 941 patients to 1,500 patients in each analysis. The use of corticosteroids should not exceed 3 continuous months without attempting to introduce corticosteroid-sparing agents (such as biologic therapy or immunomodulators). In a meta-analysis including 403 patients with surgically or medically induced remission, corticosteroids were not effective at maintaining remission (275) the rates of remission were no different between placebo and corticosteroids at 6, 12, and 24 months. The adverse events associated with corticosteroids were significantly higher than placebo at all time points and should not be used for maintenance of remission. The 12-month relapse rates for 3 to 6 mg budesonide ranged from 40 to 74% and were not significantly different than placebo. One study did show a reduction in the relapse rate compared with placebo, but this occurred at an early time point of 3 months (304). The budesonide meta-analyses included doses of budesonide at 3 and 6 mg and reported increased adverse events compared with placebo. Abnormal adrenocorticoid stimulation tests and alteration in bone mineral density were higher in budesonide compared with placebo but lower than conventional glucocorticosteroids. In the Cochrane Database review, the pooled analysis of 5 or 10 mg/kg infliximab every 8 weeks was found to be superior to placebo for maintenance of remission and clinical response to week 54, 400 mg certolizumab pegol every 4 weeks was superior to placebo for maintenance of remission and clinical response to week 26, and 40 mg adalimumab every other week or every week was superior to placebo for maintenance of clinical remission to week 54 (217). Some evidence suggests that immunogenicity may be avoided in monotherapy simply by maintaining robust trough levels of biologic therapy at all times, and that the primary effect of immunomodulator in combination therapy is in nonspecifically increasing trough biologic concentrations (318). There is a higher risk of lymphoma in patients treated with azathioprine or 6 mercaptopurine, especially among males and those patients diagnosed at younger ages (197). Natalizumab 300 mg every 4 weeks was superior to placebo in maintaining clinical response and clinical remission through week 36. Vedolizumab monotherapy is effective at maintaining vedolizumab-induced response or remission (232). Vedolizumab 300 mg every 8 weeks was superior to placebo in maintaining clinical response and remission through week 54. Because of the gut-selective nature of vedolizumab, there is no central nervous system uptake, unlike natalizumab. Vedolizumab may be administered as monotherapy; however, because of the potential for immunogenicity and loss of response, combination with azathioprine/6 mercaptopurine or methotrexate may be considered. The risks and benefits of combination therapy should be evaluated in each individual patient. The three factors that portend the greatest risk for postoperative recurrence are: (i) active tobacco smoking after surgery, especially in women and heavy smokers; (ii) patients with penetrating disease. Other risk factors for postoperative recurrence include: a shorter duration between the time of diagnosis and surgery (<10 years), disease location in the ileum and colon (rather than ileum alone), perianal fistula, more severe disease leading to surgery, a longer segment of bowel requiring resection, and the need for corticosteroids before surgery. A subsequent systematic review and meta-analysis concluded that mesalamine is of only modest benefit in preventing postoperative recurrence compared with placebo (335). Overall, mesalamine should only be considered if immunosuppressive therapy is not warranted or is contraindicated. Metronidazole (20 mg/kg) may significantly reduce the incidence of severe (i3-4) (Supplementary Information online) endoscopic recurrent disease compared with placebo-treated patients at 3 months after surgery and clinical recurrence at 1 year (336). Ornidazole (1 g/day) also decreases postoperative clinical recurrence at 1 year (337).

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Some impor tant opportunistic infections associated with therapy for cancer include Pneumocystis jiroveci (carinii) pneumonia (especially in children with leukaemia), disseminated fungal infection. Mostcommonviralinfectionsarenoworseinchil dren with cancer than in other children, but measles and varicella zoster (chickenpox) may have atypical presentation and can be lifethreatening. If non immune, immunocompromised children are at risk fromcontactwithmeaslesorvaricella,someprotection can be afforded by prompt administration of immu noglobulinorzosterimmuneglobulin. Aciclovirisused to treat established varicella infection, but no treat ment is available for measles. During chemotherapy andfrom6monthstoayearsubsequently,theuseof live vaccines is contraindicated due to depressed immunity. High-dose therapy with bone marrow rescue Thelimitationofbothchemotherapyandradiotherapy istheriskofirreversibledamagetonormaltissues,par ticularlybonemarrow. Transplantationofbonemarrow stem cells can be used as a strategy to intensify the treatmentofpatientswiththeadministrationofpoten tially lethal doses of chemotherapy and/or radiation. Thesourceofthemarrowstemcellsmaybeallogeneic (from a compatible donor) or autologous (from the patient him/herself, harvested beforehand, while the marrow is uninvolved or in remission). Allogeneic transplantationisprincipallyusedinthemanagement of highrisk or relapsed leukaemia and autologous stemcellsupportisusedmostcommonlyinthetreat mentofchildrenwithsolidtumourswhoseprognosis is poor using conventional chemotherapy. Supportive care and side-effects of treatment Cancer treatment produces frequent, predictable and often severe multisystem sideeffects. Thrombo cytopaeniapresentsthehazardofbleeding,andcon siderable blood product support may be required, particularly for children with leukaemia, those under going intensive therapy requiring bone marrow 1 2 Malignant disease 367 3 transplantationandinthemoreintensivesolidtumour protocols. Many chemo therapy agents are nauseating and induce vomit ing, which may be only partially prevented by the routine use of antiemetic drugs. Chemotherapyinduced gut mucosal damage also causes diarrhoea and may predispose to Gram negativeinfection. Drug-specific side-effects Many individual drugs have very specific sideeffects. Theextentofthesesideeffectsisnotalwayspredict able and patients require careful monitoring during, andinsomecases,aftertreatmentiscomplete. Other supportive care issues Fertility preservation Somepatientsmaybeatriskofinfertilityasaresultof their cancer treatment. Appropriate fertility preserva tiontechniquesmayinvolvesurgicallymovingatestis orovaryoutoftheradiotherapyfield;spermbanking (which should be offered to boys mature enough to achieve this); and consideration of newer techniques such as cryopreservation of ovarian cortical tissue, althoughthelongtermefficacyofthisisstilluncertain. Earlyreturntoschoolis important and children with cancer should not be allowedtounderachievetheexpectationspreviously held for them. It is easy to underestimate the severe stress that persists within families in relation to the uncertaintyofthelongtermoutcome. Thisoftenmani fests itself as marital problems in parents and behav iouraldifficultiesinboththechildandsiblings. Venous access the discomfort of multiple venepunctures for blood sampling and intravenous infusions can be avoided withcentralvenouscatheters,althoughthesedocarry ariskofinfection(Fig. Fever with neutropenia requires hospital admission, cultures and intravenous antibiotics. Psychosocial support Thediagnosisofapotentiallyfatalillnesshasanenor mous and longlasting impact on the whole family. Theyneedtheopportunitytodiscusstheimplications of the diagnosis and its treatment and their anxiety, fear, guilt and sadness. Most will benefit from the counselling and practical support provided by health professionals. Help with practical issues, including transport, finances, accommodation and care of siblings, is an early priority. Thechildrenthem selves, and their siblings, need an ageappropriate explanation of the disease.

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Diseases

  • Dwarfism syndesmodysplasic
  • Fanconi pancytopenia
  • Blastomycosis
  • Hypodermyasis
  • Inclusion-cell disease
  • Wells Jankovic syndrome
  • Willems De vries syndrome
  • Asphyxia neonatorum

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Initiating anti-inflammatory therapy before pollen season or before any repetitive aeroallergen exposure, as indicated, will modify the late-phase response that is associated with the priming effect. Use of cold compresses and irrigation with saline solution or artificial tears has been advocated to relieve mild symptoms of allergic conjunctivitis. Topical ophthalmic agents are indicated for specific treatment of itching or symptoms of allergic conjunctivitis. Vasoconstrictors are indicated for relief of ocular redness, although they do not reduce the allergic response. Prolonged use of ocular decongestants may lead to rebound hyperemia, which is often referred to as ``conjunctivitis medicamentosa. Careful consideration of the need for antimicrobial use is increasingly important because antibiotic use has been causally related to the development of bacterial drug resistance. Acute and chronic sinusitis [Summary Statements 23, 24] Distinguishing noninfectious perennial rhinitis from acute and chronic sinusitis can be difficult because many symptoms, such as mucosal erythema, increased pharyngeal secretions, olfactory disturbance, cough, nasal congestion, and headache, are found in both types of rhinitis. Although nasal cytology may be useful in differentiating infectious from noninfectious nasal and/or sinus disease, the clinical value, particularly for the diagnosis of allergic rhinitis, is limited by low specificity and sensitivity. The diagnostic validity of nasal allergen challenge for occupational allergens has not been evaluated. Chronic pharmacologic therapy as used for allergic and nonallergic rhinitis can be instituted. In general, there is insufficient evidence to support the efficacy of immunotherapy for IgE-dependent occupational rhinitis, and it is inappropriate to use immunotherapy to treat occupational rhinitis caused by low-molecular-weight chemical allergens. The most common causes of nasal symptoms during pregnancy are allergic rhinitis, sinusitis, rhinitis medicamentosa, and vasomotor rhinitis. Symptoms of allergic rhinitis increase in 1/3 of pregnant patients,118 perhaps attributed to nasal vascular pooling caused by vascular dilatation and increased blood volume. Treatment of rhinitis medicamentosa consists of suspending the use of topical decongestants and administering intranasal corticosteroids to control symptoms while allowing the rebound effects of the nasal decongestant spray to resolve. Atrophic rhinitis [Summary Statement 29] Primary (idiopathic) atrophic rhinitis is a chronic condition characterized by progressive atrophy of the nasal mucosa, nasal crusting, nasal dryness (caused by atrophy of glandular cells), and fetor. Nasal polyps [Summary Statement 30] Nasal polyps may coexist with allergic rhinitis; however, allergy as a cause of nasal polyps has not been established. Nasal polyps have a prevalence of 2% to 4%141-143 and usually occur after age 40 years. A short course of oral steroids followed by maintenance use of intranasal corticosteroid administered twice daily should follow. Unilateral obstruction, especially when associated with bleeding, hyposmia or anosmia, pain, and otalgia, should alert one to the possibility of a tumor. Whereas screening diagnostic tests for mucociliary clearance use saccharine166 or Teflon (DuPont) tagged particles, definitive diagnosis requires biopsy and examination by electron microscopy. Questions relating symptoms to pollen and animal exposure have been shown to have positive predictive value for diagnosing allergic rhinitis. Emphasis should be on the upper respiratory tract, but the examiner should carefully look for accompanying otitis191 or eustachian tube dysfunction,192 chronic sinusitis, nasal polyps, conjunctivitis, asthma,193 and atopic dermatitis. If the patient is asymptomatic or mildly symptomatic at the time of the physical examination, there may be minimal or no findings even with a history suggestive of rhinitis. Physical examination of patient presenting with symptoms compatible with rhinitis Vital signs including weight and height should be recorded in all patients. General observations: facial pallor, elongated facies, preferred mouth breathing, and any evidence of systemic disease. Eyes: Excessive lacrimation, erythema and swelling of the bulbar and/or palpebral conjunctiva, cobblestoning of the tarsal conjunctiva, swelling or dermatitis of outer eyelids, Dennie-Morgan lines, or venous stasis below the lower eyelids (``allergic shiners'). Nose: Reduced patency of nasal valve; alar collapse; transverse external crease; external deformity such as saddle nose; sepal deviation or perforation, spurs, ulcers, perforation, prominent vessels, or excoriation; nasal turbinate hypertrophy, edema, pallor or erythema, and crusting; discharge (amount, color, consistency), and nasal polyps.

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Certain cells of the immune system, found throughout the body, that remove infecting organisms from the body by engulfing and destroying them, in a process known as phagocytosis. Competition between normal, non-disease-causing (commensal) microorganisms normally found in the gut or on the skin and pathogenic (disease-causing) organisms to which the host is exposed. These defenses may be overcome by exposure to a large number of organisms or repeated exposure over an extended period of time. Defense mechanisms may 2-6 diminish when another disease-causing infection is occurring at the same time, following previous treatment with antibiotics (which wipes out commensal organisms), or when a breakdown in a barrier exists (such as a skin wound). This type of immunity usually lasts the longest period of time, often for the life of the host. Vaccination with weakened or killed infectious agents leads to active, induced immunity. Injection of antibodies or antitoxin leads to a passive, temporary immunity to an agent. Use of gamma globulin to protect against chicken pox is an example of passive immunity. To find ways to break the chain of disease transmission communicable diseases are prevented by increasing host resistance (through vaccinations); modifying the environment (to eliminate reservoirs or to interrupt transmission); inactivating the infectious agent. Vaccination Seagoing persons should be appropriately vaccinated against all diseases traditionally occurring during childhood (diphtheria, tetanus, poliomyelitis, measles, mumps, rubella, and chicken pox) and should consider vaccination to prevent hepatitis A and B. Though vaccines have reduced the occurrence of many of these diseases worldwide, susceptible travelers may still acquire these diseases. Vaccination against chicken pox is only necessary if there is no history of childhood infection. Vaccination against both hepatitis A and B and an inactivated poliomyelitis vaccine booster should be considered for adults who plan to travel and work in areas where these diseases are more common. Hepatitis A is contacted by the oral fecal route, such as from contaminated food or water. Hepatitis B may be acquired by direct or indirect contact with body fluids from an infected person. Travelers to endemic areas should consider vaccination for hepatitis A, typhoid fever, and cholera. Hepatitis A and/or typhoid vaccines are indicated for persons who travel regularly to less-developed countries and who anticipate eating locally prepared foods or drinking water. Travelers to less-developed countries are advised to avoid eating uncooked food, especially fish and shellfish, and to peel fruits themselves to minimize the risk of acquiring typhoid fever, cholera, hepatitis A, and other gastrointestinal diseases. Currently, no country or territory requires cholera vaccination as a condition for entry. Local authorities, however, may require documentation of cholera vaccination when coming from endemic or epidemic areas; in such cases, a single dose of vaccine is sufficient to satisfy local requirements. Certain diseases transmitted by mosquitos, such as yellow fever and Japanese encephalitis (a disease that occurs throughout eastern and southern Asia) may be prevented through vaccination and by avoiding mosquito bites by wearing appropriate clothing and using repellents and mosquito netting. Yellow fever vaccination is required at 10-year intervals for travel to many tropical American and African countries. Animal-borne disease such as plague and rabies may be prevented by vaccine and avoidance of unknown animals. Meningococcal disease may be prevented with vaccination when traveling to regions of higher risk: the subSaharan east-west belt of Africa, the Middle East, and the Asian subcontinent. Every seaman should keep with his or her passport and other papers, written evidence of the vaccines and prophylaxis received. The World Health Organization publishes vaccine cards, which are recommended in order to keep an accurate record of all vaccinations (Fig 2-1). Up-to-date records will prevent repeated and unnecessary vaccinations when entering an infected port or one that requires vaccination documents. Some ports may require documentation of prior vaccination for yellow fever or cholera when traveling from areas with high disease activity. If no medical officer is available and qualified to administer vaccinations, it is recommended that seamen arrange for multi-dose vaccinations during layovers ashore. Seamen should consult medical authorities at least 6 weeks before departure to obtain current health information on the countries that will be visited. Reservoir Eradication Exposure to infection can be prevented by eradicating the reservoir of infection, closing the portals of exit from the sources, and eliminating the modes of transmission.

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This is usually to avoid embarrassing older children or teenagers or to impart sensitive information. This must be handled tactfully, often by negotiating to talk separately to each in turn. The age when a child first walks is highly relevant when taking the history of a toddler but irrelevant for a teenager with headaches. Let the parents and child recount the presenting complaints in their own words and at their own pace. Ensure that the interview environment is as welcoming and unthreatening as possible. Avoid having desks or beds between you and the family, but keep a comfortable distance. While the comprehensive assessment listed here is sometimes required, usually a selective approach is more appropriate. This is not an excuse for a short, slipshod history, but instead allows one to focus on the areas where a thorough, detailed history is required. Immunisations (ideally from the personal child health record) Past illnesses, hospital admissions and operations, accidents and injuries. Comprehensive history-taking is best reserved for training or for complex, multi-system disorders. If there is a positive family history, extend family pedigree over several generations. Normal growth Pubertal development (if appropriate) Feeding/drinking/appetite Any recent change in behaviour or personality. Development Check: Make sure that you and the parent or child mean the same thing when describing a problem. When first examining a young child, start at a non-threatening area, such as a hand or knee. Explain what you are about to do and what you want the child to do, in language he can understand. As the examination is essential, not optional, it is best not to ask his permission, as it may well be refused! The area to be examined must be inspected fully but this is best done in stages, re-dressing the child when each stage has been completed. Parents are reassuring for the child and helpful in facilitating the examination if guided as to what to do. Teenage girls should normally be Warm,cleanhands Hands must be washed before (and after) examining a child. Developmentalskills A good overview of developmental skills can be obtained by watching the child play. A few simple toys, such as some bricks, a car, doll, ball, pencil and paper, pegboard, miniature toys and a picture book, are all that is required, as they can be adapted for any age. Tachypnoea Examination Initialobservations Careful observation is usually the key to success in examining children. Inspection will provide information on: Rate of respiration is age-dependent (Table 2. The general morphological appearance may suggest a chromosomal or dysmorphic syndrome.

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Fordetailsaboutincubationandexclusionperiods, see the Health Protection Agency website The other herpesviruses will be discussed in this section, in order of their prevalence. The hallmark of the herpesviruses is that, after primary infection, latency is established and there is longterm persistence of the virus within the host, usuallyinadormantstate. Asymptomatic Herpes simplex infections are very common and are mostlyasymptomatic. Therearevesicularlesionsonthelips,gumsand anteriorsurfacesofthetongueandhardpalate,which often progress to extensive, painful ulceration with bleeding(Fig. Thereisahighfeverandthechild 1 Infection and immunity 251 2 ultimatelylossofvision. Chickenpox (primary varicella zoster infection) Clinical features TheseareshowninFigure14. There are a number of rare but serious complica tionsthatcanoccurinpreviouslyhealthychildren: is very miserable. In the immunocompromised, primary varicella infec tion may result in severe progressive disseminated disease,whichhasamortalityofupto20%. Immunocompromised children should be treated with intravenous aciclovir initially. Itchy and scratching may result in permanent, depigmented scar formation or secondary infection. Protection from infection with zoster immunoglobulinisnotabsolute,anddependsonhow soonaftercontactwithchickenpoxitisgiven. It occurs most commonly in the thoracic region, although any dermatome can be affected. Shingles in child hood is more common in those who had primary infectioninthefirstyearoflife. In the immunocompromised, reactivated infection can also disseminatetocauseseveredisease. Beware of admitting a chickenpox contact to a clinical area with immunocompromised children, in whom it can disseminate and be fatal. Indevelopedcountries,abouthalfofthe adult population show serological evidence of past infection. Patientsmay have atypical lymphocytes on the blood film but are heterophile antibodynegative. The virus has a particular tropism for B lymphocytes and epithelial cells of the pharynx. Transmission usually occurs by oral contact andthemajorityofinfectionsaresubclinical. They classically causeexanthemsubitum(alsoknownasroseolainfan tum),characterisedbyahighfeverwithmalaiselasting a few days, followed by a generalised macular rash, whichappearsasthefeverwanes. Manychildrenhave a febrile illness without rash, and many have a sub clinicalinfection. Rarely, they may cause aseptic meningitis, encephalitis, hepatitis, or an infectious mononucleosislikesyndrome.

References:

  • https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021368s20s21lbl.pdf
  • http://www.numc.edu/wp-content/uploads/old/our-services/primary-care/why%20dsmV%20should%20have%20returned%20to%20kraepelins%20concpet%20of%20manic%20depressive%20illness.pdf
  • http://edmedia.emory.edu/GStaton/Anoxic,%20Metabolic,%20and%20Toxic%20Encephalopathies.pdf
  • https://foodsafety.foodscience.cornell.edu/sites/foodsafety.foodscience.cornell.edu/files/shared/documents/CU-DFScience-Notes-Dairy-Cultures-HomoHeteroferm-10-08.pdf
  • https://www.aafp.org/afp/2001/0115/afp20010115p326.pdf