Childhood Obesity

Obesity is a common problem affecting children and adolescents. This is a result of both increased intake of energy-dense foods (high-fat diet, fast foods) and reduced exercise.

Energy expenditure has fallen as a result of an increase in sedentary behavior. Children spent lot of time in front of computers and television. They have less chance to play outdoor games due to competitive education and extra classes.

Other causes of obesity are hypothyroidism, Cushing's syndrome and some syndromes like Prader-Willi syndrome.

Emotional disturbance is seen in some affected children and unhappiness may lead to further excessive eating.

Complications of obesity are bone deformities (bow legs), headache, heart failure, polycystic ovaries, hyperinsulinaemia or non-insulin-dependent diabetes mellitus, hypertension, abnormal blood lipids, asthma and psychological problems like low self-esteem, depression.

To get rid of this problem child should reduce in television viewing and fat intake, increase physical activity (30 to 60 minutes of moderate or vigorous physical activity per day), increase fruit and vegetables intake. Of these, the most effective single factor is reduced television viewing. There is no evidence that any drug treatment is effective in treating obesity in children.

Important to notice

Obesity in children is becoming more common

Predispose children to a wide range of medical illness such as diabetes, high blood pressure and psychological distress in childhood and adult life.

An obese child tends to become an obese adult.

Most children are obese as a result of their lifestyle not due to an underlying medical problem.

Lifestyle changes are difficult to achieve and even harder to maintain.

Success is more likely if there is family support and participation. Therefore family support is necessary to get rid of this problem.

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HEAT test for URINARY PROTEIN....Method of doing and reading at HOME

To perform the heat test, two thirds of a test tube is filled with urine. It is held at a slant and the lower half of the tube is heated until boiling point.

If turbidity appears, two drops of 10% acetic acid (vinergar) are added to exclude the possible presence of phosphates. If this turbidity due to phosphate, turbidity will disappear after adding acid. The degree of turbidity is read against a background of black print. Proteinuria is graded according to the degree of turbidity.

Grading of proteinuria

Nil -          no turbidity

Trace -     slight turbidity with no difficulty in reading the print

+ -             clouding of the print but possible to read the print

++ -          cannot read the print but can notice black

+++ -        cannot notice black

++++ -      cannot notice black and with precipitate

The sulphosalicylic acid test also a recommended test to detect proteinuria.

The sulphosalicylic acid test is performed by adding 2 drops of 30% sulphosalicylic acid to 5 ml of urine in a test tube and observing the resulting turbidity. Grading of proteinuria is similar to the heat test. 

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Patient and Parent Education about NEPHROTIC SYNDROME

What you should know about Nephrotic syndrome......

In nephrotic syndrome lot of protein pass through kidneys result in a low plasma protein (albumin) and oedema (body swelling).

Prognosis

One third of children resolve directly, another one third continue with infrequent attacks and other one third become Steroid dependent (two consecutive relapses occurring during corticosteroid therapy or within fourteen days after its cessation). 10%- 15% of children become steroid resistant.Reassurance that progression to end stage renal failure is extremely rare is important.

Parental motivation and involvement is essential in the management of a child with nephrotic syndrome. Patients and parents who have a clear understanding of the disease comply better with treatment. 

Prior to discharge following treatment of the initial episode – the following aspects of management must be emphasized.

• Urine examination for protein at home. Parent/patient should have a clear understanding of grading proteinuria. How to do....(click here)
• Examination should be done every morning during a relapse, during intercurrent infection or if the child has even mild periorbital oedema.
• Urine is examined twice / thrice a week during remission.
• The dipstick test is carried out by dipping the marked end of the strip in urine for 3 seconds and comparing the colour change with the code given in the pack

• Maintain a diary showing proteinuria, medications received and intercurrent infections. 

• Ensure normal activity and school attendance. It is important that the child participates in all activities and sports.

• Bed rest.     This is not required and could be harmful. (Predisposes to thrombosis)

• Fluid restriction.   This is usually not recommended.

• Infections are an important cause of morbidity and mortality and parents need to understand the measures needed for preventing frequent infections (avoid crowded place…..) and the importance of seeking early treatment for infections (fever, cough, excessive crying, abdominal pain).

• Diet.      It is important to give clear instructions as most parents have their own views and beliefs regarding dietary restrictions in kidney diseases. A balanced diet adequate in protein and calories with a protein intake of 1.5-2 g/kg/day is recommended. A high protein diet had not been shown to improve serum albumin concentration. (The average Sri Lankan diet contains approx. 0.8g/kg/day of proteins) Not more than 30% calories should be derived from fat and saturated fats should be avoided. Carbohydrates are best given in complex forms. A modest reduction in salt is advised in the presence of oedema. Snacks containing high salt are best avoided during this period. Fruits and fruit juices can be given without restrictions. Corticosteroids stimulate the appetite, and advice should be given about ensuring physical activity and preventing excessive weight gain.

• All killed vaccines included in EPI programme should be offered to these children preferably while receiving alternate day prednisolone. Parents must be made aware that live vaccines are contraindicated while on treatment with steroids.

Live vaccines are contraindicated in children receiving high dose systemic steroids (prednisolone 2mg/kg/day or 20mg/day in children >10kg body weight ) until the steroids have been discontinued for 3 months. (BNF;2006, SLMA guidelines on vaccines:2004)

Hepatitis B vaccine should be given to all the children who were not vaccinated previously.

• Educate about prednisilone. 
• Admit the child if there is oedema and +2protein for more than two days at home.

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Prescribing in pregnancy

There are marked and progressive physiological changers during pregnancy which can alter pharmacokinetics. And also drug given in pregnancy can affect the baby. So special attention should be given to prescribing in pregnancy.

Alter pharmacokinetics

Absorption 

Delay absorption due to reduce gastrointestinal motility. So oral drug get some time to absorption. But no magor defect in drug absorption. In acute conditions intramuscular route can use because vasodilation lead to increase tissue perfusion.

Distribution

Total body water increase by to 8 liters. So volume of distribution increase in water soluble drugs.
Plasma albumin level get decrease and α₁ acid glycoprotein get increase. So free fraction of acidic drugs get increase and free fraction of basic drug get decrease.
Body fat increase by about 4kg. It act as a reservoirs for lipid soluble drug.

Metabolism

Hepatic microsomal enzymes undergo induction. so many drugs metabolise faster. The placenta also contribute to part of this.

Elimination

Renal plasma flow get doubles and so rapid elimination in renal eliminating drugs.
Eg:- Amoxicillin dose should double in systemic infection.

Affect the foetus

The lipid soluble drugs and drugs which have low molecular weight (less than 600) enter to foetal blood. But water soluble compounds and drugs which have high molecular weight does not enter to foetal blood. But in prolonged use any drug can enter to foetal blood to some extent.
During first trimester drugs can produce congenital malformation (teratogenesis). The greatest risk carried out from third week to eleventh week.
During second and third trimester drugs can produce growth or functional abnormalities in foetus.
Drugs give shortly before labour Can have adverse effect on labour.

Important
Avoid newer drugs, unless safety is clearly established.
Use the minimum effective dose.
Use drugs for the shortest period necessary.

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Medicine OSCE 2

Write the answers your self and compare......

1.What is the abnormality seen in this chest radiograph

2. Give two likely causes for this condition


Answer

1) Air- fliud level in the left hemithorax (6)

2) Hemopneumothorax(2), pyopneumothorax (2)  

Discusion

            

Collection of fluid in the pleural space with an air- fluid level is seen with lung abscess, hemopneumothorax and pyopneumothorax.

 Lung abscess is characterized by a such collection with a well demarcated capsule and when the air fluid level is seen across the hemi thorax without a capsule it is due to hemopneumothorax and pyopneumothorax. These can arise as a rupture of lung abscess (pyopneumothorax) or following trauma ( hemopneumothorax)

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Medicine OSCE 1

52 year old patient presented with cough and several bouts of haemoptysis of four month duration.  

1. Describe two abnormalities on chest Xray

2.  Give a likely diagnosis     

Answer

1. a) Two opacities in the upper zones of the left lung

   b) cavitations with thick walls in the left upper zone 

2. malignant lesions with central cavitations

 
Discusion

Lung opacities with irregular margins are features of either primary or secondary malignancy. Cavitations within the lesion also favor this. Cavitations with thick irregular walls are more in favor of a malignant lesions. Always look for erosion of ribs, hilar lymph node enlargement, calcifications and plural effusion(which are not present in this case) when there is suspicious malignant lesions in the lung.

Squamous cell carcinoma commonly present as a large peripheral mass with central cavitation.

primary sites of pulmonary metastasis

female- breast, tthyroid

male- testis, colon

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Fever - What you should know...

What is a fever ?

A fever is when the body’s temperature is higher than normal. Humans usually have a body temperature within a very narrow range. Normally a child has a fever when their temperature is over 37.5ºC (when taken by a thermometer under the arm). A child with a fever often has a hot, flushed face. The forehead may feel hot. The child may feel hot, or sometimes even shivery. A child’s hands and feet may feel cold, even when the rest of the child is hot. Children with fever

are often miserable or tired.

Is fever good or bad ?

Fever is the body’s natural response to infection. Raising the body temperature helps the body to fight off the infection, so it is not always necessary to treat the fever. However, children with fever often feel uncomfortable and unwell. Using measures to bring down their temperature can help. Fevers, especially if they are rapidly increasing, may occasionally bring about convulsions (fits)in children under five years old. These are not dangerous but they can be frightening.

Keeping a child’s temperature from getting too high may prevent fits.

What causes fever ?

The most common cause of a fever is infection. Infections of the upper respiratory tract, such as colds and flu, are very common, especially in preschool children. These infections are caused by a virus and get better on their own without antibiotics. Some infections, like ear infections and some throat infections, may be caused by bacteria. If your child has a bacterial infection, he or she will get better much quicker if antibiotics are prescribed by a doctor. Fever may also be caused by other factors, such as prolonged exposure to the sun on a hot day.

When do you need to see a doctor ?

You need to see a doctor if your child has a fever and:

• Your child is very young (six months or younger)
• Your child seems very sick.

You also need to see a doctor if your child: 

• has an earache 
• has difficulty swallowing 
• has fast breathing 
• has a rash 
• has vomiting 
• has neck stiffness 
• has bulging of the fontanelle (the soft spot on the head in babies) 
• is very sleepy or drowsy 
• you are concerned.

Older children who have a cold, but are not very sick, generally do not need to see a doctor with every fever.

Managing a fever

Since a fever is the body’s natural response to infection it is not always necessary to reduce a fever. However, if your child is very hot and uncomfortable, you can try these simple steps:

• Take off your child’s clothes.
• Give medications to reduce fever, eg paracetamol . This medication should be given at the correct dose, so ask your doctor or refer the instructions on the bottle for the correct dose.
• Give your child plenty to drink as children with a fever need more fluids.
• Consult a doctor if the fever does not settle or your child is still sick.

Impotent to Remember 

• Most fevers are caused by viral infections.
• Make sure your child drinks plenty of fluids.
• Babies under six months with a high temperature should be seen by a doctor.
• See a doctor if your child seems very sick.

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Differential Diagnosis for convulsions (fits) for a child

This post mainly consist differential diagnosis and how it can differentiate

Meningitis / Encephalitis

• Fever,
• Drowsines,
• Irritabilit,
• Photo phobi,
• History of upper respiratory track infection or Ear discharge
• Purpuric skin rashers (Neisseria meningitidis)
• Neck stiffness
• Skin infection (Staphylococcus aureus)

Tuberculous Meningitis

• Contact history of Tuberculosis
• BCG scar
• Mantoux test

Cerebral malaria

• Travel to malaria endemic erea
• Fever with chills and rigours

Febrile convulsions 

  A febrile convulsion is a seizure that occur between the age of 3 months to 6 years with fever that is not result of central nervous system infection or any metabolic imbalance, and that occur in the absence of a history of prior afebrile seizures.

• Benign
• Occur with fever
• Age 6 month to 5 years
• Less postictal drowsiness
• Usually less than 15 min ( if more than it, It is a complex febrile convulsions.)

Difference of simple and complex febrile convulsions

Simple febrile convulsion

• Less than 15 minutes (few seconds)
• Primary generalized 
• Usually tonic clonic
•  Not recurrent within a 24 hour period
• Chance of developing subsequent epilepsy is not increased. Same as all children (1- 2%). 

Complex febrile convulsion

• Continue more than 15 minutes,
• Focal,
• Recurs within 24 hours,
• Chance of developing subsequent epilepsy is increased. (4- 12%)

Epilepsy

• Long postictal drowsiness
• Past history of convulsions
• Antyepileptic drug withdrawal
• Neurocutaneous markers on skin

       pic.1 cafe au lait patches,(black arrows) neurofibroma (white)

Metabolic causes

• Hypoglycemia
• fasting, associated with sweating
• Hyponatraemia
• vomiting, diarrhea

Head trauma

Toxins and drugs

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How to convert biochemical reference level

You should multiply SI units by conversions factor

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Barthel Index

            Activity                                                                                                 Score

FEEDING
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent 

BATHING
0 = dependent
5 = independent (or in shower)

GROOMING
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided)

DRESSING
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)

BOWELS
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent

BLADDER
0 = incontinent, or catheterized and unable to man
5 = occasional accident
10 = continent

TOILET USE
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)


TRANSFERS (BED TO CHAIR AND BACK)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent


MOBILITY (ON LEVEL SURFACES)
0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards

STAIRS
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent

Final score                                                                                                      .................../100

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