COPP MODULE

COMMON OFFICE PRACTICE PEDIATRIC PROBLEMS[A MODULE OF IAP TAMILNADU STATE CHAPTER 2017]

TEAMScientific advisors Dr P Ramachandran,Dr S BalasubramanianConveners Dr S Thirumalai Kolundu,Dr Sunil SrinivasanScientific Coordinator Dr A Somasundaram Academic coordinators Dr S Narmada,Dr R.V Dhakshayani Academic committee [MODERATORS]

Dr NC Gowrishankar,Dr T N Manohar,Dr K Nedunchelian,Dr Rema Chandramohan,Dr R Somasekar,Dr S Thangavelu,Dr V V Varadarajan

CONTRIBUTORSDr RV Dhakshayani Dr A SomasundaramDr Giridhar Dr Somu SivabalanDr Hemchand K Prasad Dr S SrinivasDr E Mahendar Dr P SudhakarDr S Mangalabharathi Dr Sudharshana skanda Dr Manikandan Dr B SumathiDr Manikumar Dr Suresh Dr S Narmada Dr VenkateshwaranDr Palaniraman Dr C VijayabhaskarDr R Selvan

Dr.S.Narmada MBBS, DNB, PGDDN,Dip in Allergy and Asthma, MRCPCH, MBA

• Director and Consultant Pediatrician, Nalam Medical Centre and Hospital, Vellore

• Posts Held– Founder member in IAP National Women’s wing, South Zone Coordinator– Treasurer, IAP TNSC, 2017-18, Editor, IAP State Bulletin, 2014– EB member, IAP North Arcot, 2016,– Secretary, IAP, North Arcot, 2012-2015– Organising Secretary, South Pedicon 2015– Associate Editor for IAP Textbook of Management Algorithm for Common Pediatric Illness– Associate Editor, IAP Textbook on Practical Pediatric Digest

• Speaker in National and State IAP Conferences• Publications and Research articles:

– Balagopala Raju Gold Medal Award for Best paper Pediatric State Level Conference 2014– Adjudged 2nd best poster for research article on “Phenotypic and genotypic features of Asthma and allergic patients in Vellore”

at National Respiratory Conference Respicon 2015.– Coauthor of ““MCP3 polymorphism, environmental risk factors and asthma- a hospital based study in Vellore” published in

the International Journal of Pharma and Bio Sciences under Biological Sciences, Vol 7(2). – First author of chapter on Allergen Immunotherapy in the book titled "ALLERGY AND ALLERGEN IMMUNOTHERAPY ; New

Mechanisms and Strategies " to be released in October 2016 by American Academy of Pediatrics Publications 2016

• Authored chapters on allergy testing and urticaria in the book titled IAP Textbook on Practical Pediatric Digest by Jaypee Publishers 2016

Scabies and lice treatmentUrticaria - Treatment

Dr. Narmada AshokConsultant Pediatrician,

Nalam Medical Centre &Hospital,Vellore

ModeratorDr. Gowri Shankar,

Consultant Pulmonologist and Pediatrician

Scabies

• Sarcoptes scabeii var homins – most common Obligatory ectoparasitic dermatosis seen

• Not life threatening but extremely distressing• Impetiginised cases can cause Acute glomerulonephritis• Highest prevalence is seen in children below 2 years of age• Point prevalence in India – 5%• Predisosing factors – overcrowding, poor hygiene,

population shifts and sexual contact• Source of transmission – close personal contact

Causative agent

• Sarcoptes scabeii var hominis• Female mite (black dots

shown by arrows) -lay eggs- stratum corneum

• Burrows - hallmark • Female mite is bigger than

male.• Life cycle of 30 days . Lays 11

to 25 eggs• Incubation period- 3-4 weeks

Clinical features

• Intense itching worse at nights. Similar history in family

• 2 main types of skin lesions– Burrows – Erythematous papular eruption

• Secondary lesions – eczematisation, excoriations and secondary infections occur

Clinical features

• Site of predilection – Interdigital clefts of hands – Wrist – flexor aspect– Elbow- extensor aspect– Anterior axillary folds– Areolae of breast– Periumbilical area– Gluteal cleft and genitalia

• Infant – Vesicular lesions-

palm and soles

Scabies- Variants

Nodular scabies• Infants & young children• Hypersensitivity to

retained organisms• May persist for months

after eradication of mites

• Erythematous, 5 to 6 mm- groin, genitals, axillary folds, buttocks.

Scabies incognito• Due to steroidsNorwegian scabies • Immunocompromised

children & mentally ill children

Animal or canine scabies

Treatment• Treat all family members

at same time• Bedding, clothing, towels

-used by index case or close contacts anytime during 3 days before treatment – decontaminated (scabies mite do not survive beyond 2-3 days away from human skin)

• Application at bed time • In infants - head to toes /

in children & adolescents - from neck downwards

• After 8-12 hours contact –bath

• Second application after a week

• Norwegian scabies - require more application

Scabicidal agentsScabicidal Agent

Strength Formulation Applications Remark

Permethrin 5% Cream One overnight Most effective least toxic

Gamma benzene hexachloride

1% Lotion, cream One only. Children below 5 only 2 hours application

Potentially toxic, avoided in children below 2 years

Benzyl benzoate

12.5% (children)25% (Adol, adults)

Lotion, emulsion

3 applications at 12 hrs interval

Tendency to irritate the skin

Sulphur 5 %(children)10 % (adolescents, adults)

Precipitated in petroleum

Three consecutive nights or multiple application.

Safe, inexpensive, Malodorous,

Crotamiton 10% Cream Twice daily application for 3-10 days.

Less effective. Useful for post-s c a b i e t i c itching.

Ivermectin 200 mcg/kg orally**(not to be used in children <15kg)

Tablets Single oral doseFollowed by second dose after a week

Though effective, its safety profile needs to be established.

•Treatment of secondary infection with antibiotics is necessary•Proper treatment of presenting cases and their contacts during epidemics and localised outbreak is a good approach•Itching – may persist for 2 weeks•Ivermectin used for bullous scabies, crusted scabies

Difference between classical and neonatal scabies

Pediculosis

• Head louse – Pediculus humanus capitis• Body louse – Pediculosis humanus corporis• Pubic or crab louse - Pediculosis pubis • Can also occur in places like eyebrows or

eyelashes, trunk, extremities and axilla

Clinical diagnosis

• Scalp pruritus• Exam – excoriations and dark specks on the scalp, crusted

lesions with secondary infection with matting of hair and posterior cervical adenopathy may be present

• Nits - easily identifiable - glued to hair- 4mm away from root- back of head

• Commonest areas to find nits are behind ears and nape of neck

• Differentiation should be made from Seborrheic dermatitis – presence of large plaques – oily skin

General guidelines• Treatment of choice - permethrin or lindane • 2 applications is ovicidal • After treatment- nits removed by dry combing or

soaking hair with white vinegar (3% to 5% acetic acid) or 8% formic acid rinses to soften the cement of nits before combing hair

• Eyelashes infestation – petrolatum applied 3 to 5 times a day can asphyxiate lice and nits

• Secondary pyoderma to be treated with cotrimoxazole

Treatment guidelinesDrug Strength Formulation Applications

Permethrin 1% Hair rinse, gel, shampoo

2 applications a week apart. Contact time 10 minutes

Gamma benzene Hexachloride

1% Lotion, shampoo

2 applications a week apart. 5 minutes for shampoo and 12 hrs for lotion

Malathion 0.5% Solution 2 applications. Contact time 12 hours

Crotamiton 10% Cream, lotion 2 applications week apart. Contact time 24 hours

Cotrimoxazole 80mg of trimethoprim and 400 mg of Sulfamethoxazole

Tablets and kit 1- 2 tablets twice a day for 5 days. Can be repeated after 10 days

Ivermectin 200microg/kg tablets Single dose. More RCT needed

Non Pharmacologic treatment – 1. Wet combing2. Delivery of hot air 3. Cetaphil Gentle skin cleanser – dry -on suffocation -based pediculocide

Acute Urticaria

Urticaria• common heterogenous group of disorders

with varied etiology• appearance of fleeting wheals – lasting 1- 24

hours +/- angioedema lasting upto 72 hours• Lesions polymorphic - rapidly grow and

coalesce without residual lesions• May persist up to 1- 5 years• 1 in 5 people will have urticaria in life time

Classification

• Duration and frequency based– Acute <6 weeks– Chronic >6 weeks

• Timeline 6 weeks - daily or near daily symptoms - arbitary dividing point

• In children - commonest - acute urticaria

Types Subtypes Definition/Eliciting factors

Spontaneous urticaria

Acute Spontaneous wheals and/or angioedema < 6weeks

Chronic Spontaneous wheals and/or angioedema > 6weeks

Physical Urticaria

Cold contact Eliciting factor: cold objects/wind

Delayed pressure Eliciting factor: vertical pressure

Solar urticaria Ultraviolet or visible light

Dermatographic Mechanical shearing forces

Vibratory urticaria Vibratory forces

Other types Aquagenic water

Cholinergic Increase of body core temperature

Exercise induced anaphylaxis

Physical exercise

In children..

• Upper respiratory tract and viral infections – commonest

• Food allergy though not important – eggs, milk, peanuts, treenuts, fish and shellfish

• Food additives – monosodium glutamate and sweeteners

• Insect stings• Transfusion • Latex sensitivity• Autologous antibody in

chronic urticaria – present in some

• Specific cause not identified in 50%

Chronic Urticaria: Indian Context Challenges and Treatment Options: Dermatol Resp Prac 2013: Sujoy et al

Urticarial MimicsCondition Distinguishing CharacteristicsArthropod Bites Lesions last several days, H/O exposureAtopic dermatitis Maculopapular, scaling, characteristic

distributionContact dermatitis Indistinct margins, PapularErythema Multiforme Lesions last several days, Target

appearanceHenoch Schonlein Lower extremity distribution, purpuricPityriasis rosea Lesions last weeks, Herald patchViral exanthem Not pruritic, prodrome, fever, individual

lesions last for several daysMorbilliform drug reactions

Maculopapular associated with medication

Urticaria Activity Scoring

Investigations in acute urticaria

• No investigations except when suggested by history• Ig E mediated reactions to environmental allergens

such as latex, nuts, fish and certain antibiotics can be confirmed by skin prick tests or RAST

• Single blind oral challenge with food additives – appropriate clinical setting

Interventions

• Nonspecific aggravating factors – overheating, stress, codeine should be minimised

• Cooling antipruritic lotions – calamine or 1% menthol in aqueous cream can be soothing

• Cold compresses can be used

• Pharmacologic treatment for symptomatic relief

Antihistamines

• These are the first line of treatment

• 1st Generation – Chlorphenaramine, Hydroxyzine and Diphenhydramine

• 2nd Generation – Fexofenadine, cetrizine, Loratidine, Desloratidine

• WAO recommends 2nd generation antihistamines as the initial pharmacotherapy

1st Vs 2nd Generation antihistamines

• Serious side effects with 1st generation

• Penetration of BBB and binding to H1 receptors in CNS and interference with neurotransmitter effects of histamine

• Affect REM sleep , impact learning & performance

• 2nd generation antihistamines upto 2 fold recommended dosage control symptoms in majority.

• Potential benefits outweigh risk associated

• Cetrizine - shortest time to attain maximum concentration & rapid bioavailability

Dosing

• Give choice of atleast 2 antihistamines - response may vary between individuals

• Timing of medications - ensure that highest drug level are obtained when urticaria is anticipated

• Should be taken daily• Sedating antihistamines - night to sleep better (additional

clinical effect on urticaria is doubtful if receptors are already saturated )

• Off licence addition of H2 antihistamines- Ranitidine and Famotidine may give better control in some individuals

Life saving drugs

• Epinephrine– Life saving when urticaria is associated with anaphylaxis

and angioedema.– First line of treatment in such emergencies– Epipen (150µg) is recommended if history indicates risk of

further life threatening attacks

• Corticosteroids – Short duration of 3 days is recommended– Long courses not beneficial– More used in angioedema

Prognosis

• Acute urticaria prognosis is excellent with most cases resolving in days; however prognosis of CU is variable but unusual in children

• Very few studies are available in children• Hospital admissions for urticaria is 3 times higher in

children aged 0-4 years than for other ages• Among those affected with urticaria 20 -30% of

children progress to chronic urticaria which is concerning

Take home messages

• Acute urticaria is a common disorder in children• Mast cells are the primary effectors• About 20% of children may progress to CU• Diagnosis is based on thorough clinical history

however tests for IgE may be used in some instances

• 2nd generation antihistamines at higher doses is the main stay of treatment