Dr. Robert YuenCommon Childhood Diseases and Initial Management

Common Symptoms ofCommon Symptoms of

Diseases in Early Diseases in Early Childhood and Childhood and

its Initial Managementits Initial Management

Respiratory DistressRespiratory Distress

•Ddx:Ddx:

• Inspiratory StridorInspiratory Stridor

•Expiratory WheezeExpiratory Wheeze

•Tachypnoea (ie. Increased Tachypnoea (ie. Increased respiratory rate)respiratory rate)

• Increased Respiratory EffortIncreased Respiratory Effort

Inspiratory StridorInspiratory Stridor

•Foreign bodyForeign body

•Acute croup Acute croup (largynocotracheobronchtis)(largynocotracheobronchtis)

•Acute epiglottitisAcute epiglottitis

•Acute retropharyngeal abscessAcute retropharyngeal abscess

•Acute peritonsillar abscessAcute peritonsillar abscess

Expiratory WheezeExpiratory Wheeze

•Foreign bodyForeign body

•Acute bronchiolitisAcute bronchiolitis

•Acute wheezy bronchitisAcute wheezy bronchitis

•Early Bronchial AsthmaEarly Bronchial Asthma

Other Causes of Resp Other Causes of Resp DistressDistress•Viral and bacterial pneumoniaViral and bacterial pneumonia

•Metabolic acidosis secondary to Metabolic acidosis secondary to dehydration and diarrhoeadehydration and diarrhoea

•Drug overdose including Chinese Drug overdose including Chinese medicinemedicine

•Inborn errors of metabolism (IEM)/ Inborn errors of metabolism (IEM)/ Inherited metabolic disease (IHD)Inherited metabolic disease (IHD)

Fever in ChildrenFever in Children

• Infection Infection –– viral, bacterial, TB, fungus viral, bacterial, TB, fungus

• eg. URTI (pharyngitis), pneumonia, eg. URTI (pharyngitis), pneumonia, meningitis, otits media.urinary tract meningitis, otits media.urinary tract infection, speticaemia, osteitisinfection, speticaemia, osteitis

• Reactive Reactive ––dehydration fever due to poor dehydration fever due to poor feeding and vomitingfeeding and vomiting

• Malignancy eg. leukaemia, lymphomaMalignancy eg. leukaemia, lymphoma

• KawasakiKawasaki’’s disease, autoimmune diseases disease, autoimmune disease

Loose stoolLoose stool

• Distinguish bloody stool and melaenaDistinguish bloody stool and melaena

• Diarrhoea Diarrhoea –– viral eg. Rotavirus, bacteria viral eg. Rotavirus, bacteria eg. Salmonella, Campylobactor, typhoid, eg. Salmonella, Campylobactor, typhoid, malabsorption eg. Lactose intolerancemalabsorption eg. Lactose intolerance

• Bloody Bloody –– intussuception, anal fissure, intussuception, anal fissure, ShigellaShigella

• Melaena (ie. Tarry stool) Melaena (ie. Tarry stool) –– massive massive gastrointestinal bleeding, volvulusgastrointestinal bleeding, volvulus

Initial ManagementInitial Management• 1. treat emergency 1. treat emergency ––basic life support, basic life support,

airway position, posture, suction and airway position, posture, suction and oxygen, gentle restraint during convulsion, oxygen, gentle restraint during convulsion, advanced life support (PALS)advanced life support (PALS)

• 2. shout for help, telephone advice, video-2. shout for help, telephone advice, video-consultation and call ambulance, consultation and call ambulance,

• 3. identify treatable causes3. identify treatable causes

• 4. good and timely communications with 4. good and timely communications with parents, supervisory officers and medical parents, supervisory officers and medical personnelspersonnels

Learning PointsLearning Points

Preventive, Proactive MeasuresPreventive, Proactive Measures

Early Diagnosis and treatmentEarly Diagnosis and treatment

Continuous healthcare educationContinuous healthcare education

Risk assessment and managementRisk assessment and management

Effective communications and team Effective communications and team workwork

Vaccination in childrenVaccination in children

Dr. YUEN Kar Ngai RobertFRCP FRCPCH FRCPE

FRCPG FHKAM FHKCPaed1309 363 Nathan Road Jordan

Tel: 23880078

Immunization Program Immunization Program in Hong Kong (1)in Hong Kong (1)

Newborn: - B.C.G. Vaccine - Polio Type I - Hepatitis B Vaccine – First dose

1 month: - Hepatitis B Vaccine – Second dose

Immunization Program Immunization Program in Hong Kong (2)in Hong Kong (2)

2-4 months:

- DPT Vaccine (Diphtheria, Pertussis & Tetanus) – First Dose - Polio Trivalent - First Dose

3-5 months: - DPT Vaccine (Diphtheria, Pertussis & Tetanus) - Second Dose

4-6 months: - DPT Vaccine (Diphtheria, Pertussis & Tetanus) - Third Dose

- Polio Trivalent - Second Dose

Immunization ProgramImmunization Program in Hong Kong (3) in Hong Kong (3)

6 months: - Hepatitis B Vaccine - Third Dose

1 year: MMR Vaccine (Measles, Mumps & Rubella) - First Dose

1 1/2 year: DPT Vaccine (Diphtheria, Pertussis & Tetanus) - Booster Dose

Polio Trivalent - Booster Dose

Immunization program Immunization program in Hong Kong (4)in Hong Kong (4)

Primary 1: DT Vaccine (Diphtheria & Tetanus) - Booster Dose

Polio Trivalent - Booster Dose MMR Vaccine (Measles, Mumps & Rubella) -

Second Dose

Primary 6 DT Vaccine (Diphtheria & Tetanus) - Booster Dose

Polio Trivalent - Booster Dose

Hepatitis B vaccineHepatitis B vaccine

All newborns should receive monovalent recombinant Hep B vaccine within 12 hours after birth (AAP)

Babies born to mothers with HBsAg-positive should receive Hep B vaccine and Hepatitis B immune globulin (HBIG) within 12 hours of birth

Hepatitis B vaccine program should be completed with either monovalent Hep B vaccine or combination vaccine at 1-2 months old and final third dose at age of >24 weeks (AAP)

Infanrix-IPV + Hib (GSK)Infanrix-IPV + Hib (GSK)

5 in 1 Diphtheria toxoid, tetanus toxoid three pertussis antigens (pertussis toxoid,

filamentous haemagglutinin and pertactin) Three inactivated polio virus (type 1, type 2 and

type 3) Purified capsular polysaccharide of Haemophilus

influenzae b covalently bound to tetanus toxoid

Primary vaccination of 5 in 1Primary vaccination of 5 in 1

Three doses in the first 6 months of life and can start from age of 2 months.

An interval of at least one month should be maintained between subsequent doses

A booster dose is recommended in the second year of life

Deep intramuscular injection in the anterolateral thigh

Infanrix-hexa (GSK)Infanrix-hexa (GSK)

6 in 1Diphtheria toxoid, tetanus toxoidThree pertussis antigens Three inactivated polio virus (type 1,Type 2 and type 3)Purified capsular polysaccharide of H.Influenzae bRecombinant HBsAg protein

Infanrix-hexa (GSK)Infanrix-hexa (GSK) Indicated for primary immunization against Diphtheria, tetanus, poliomyelitis, pertussis, hepatitis B and

Haemophilus influenzae type b in infants from age of 6 weeks and may be given to infants who received a first dose of hepatitis B vaccine at birth

Primary vaccination of three doses with at least one month in between doses

No recommendations for booster dose in the second year of life because of limited data

Deep intramuscular injection History of febrile convulsion and family history of

convulsion do not constitute contra-indications

Pneumococcal conjugate Pneumococcal conjugate Vaccine ( Prevenar)Vaccine ( Prevenar)

Polysaccharide from seven common capsular antigen of Strept pneumoniae serotypes 4, 5B, 9V, 14,18C, 19F and 23F individually conjugated to diphtheria carrier protein

Indicated for active immunization of infants and children from 6 weeks to 9 years of age against invasive disease, pneumonia and otitis media caused by Streptococcus pneumoniae.

2 months old : 2,4,6,12-15 months 7-11 months old: two doses one month apart and third dose

in second year 12-23 months old: two doses 2 months apart Over 24 months old: one dose

23-valent Pneumococcal 23-valent Pneumococcal Polysaccharide VaccinePolysaccharide Vaccine

Used for children over 2 years old and adult Contains part of the polysaccharide coat that

surrounds the 23 types of pneumococcal bacterium

These 23 types of bacteria cause about 96% of all pneumococcal diseases cases in UK

Infants who received pneumococcal 7-valent conjugate vaccine could also have the 23-valent polysaccharide vaccine from 2 years old to cover them against the wider range of serotypes

Varilrix (GSK)Varilrix (GSK)

Live attentuated varicella-zoster virus Indicated for active immunization of healthy

patients as from 12 months old and susceptible high-risk patients and their susceptible healthy close contacts eg. acute leukaemia, chronic disease

Subcutaneous route only 12 months – 12 years: one dose 13 years and above : two doses with interval of 6 –

10 weeks

Hepatitis A vaccineHepatitis A vaccine

Inactivated hepatitis A virusIndicated for active immunization of

subjects at risk of exposure to Hep A virusUsed for children over one years oldBooster dose at 6 to 12 months later to

ensure long term protectionIntramuscular injection

Fluarix- inactivated influenza Fluarix- inactivated influenza vaccine (GSK)vaccine (GSK)

Recommended for prophylaxis against influenza in adults and children older than 6 months

Especially recommended for adults over 60 years old, patients with chronic lung disease, chronic heart disease, uraemia, diabetes, congenital and acquired immune deficiency, healthcare personnels.

A second dose should be given for children who have not previously been vaccinated after an interval of at least 4 weeks

Vaccinated before the beginning of the influenza season and repeated every year with vaccine of updated antigen composition

Meningococcal C conjugate Meningococcal C conjugate (MenC)(MenC)

Primary vaccination program in UK at 2, 3 and 4 months old (Australia MenCCV: 12 months old)

Protects against septicaemia and meningitis caused by Meningococcal Group C

Also available to adults under 25 years old: greater risk for people aged between 20 and 24 years old

MPSV4 and MCV4MPSV4 and MCV4

Meningococcal polysaccharide vaccine (MPSV4) and meningococcal conjugate vaccine (MCV4) against 4 types of meningococcal disease licenced in USA.

MCV4 preferred for people 11-55 years and all children at routine visit at 11 years old

MPSV4 should be used for children 2-10 years old and over 55 years at risk.

Well Child Care and Health Supervision

Newborn

• History of maternal illness etc.

• Blood test for Blood group, G6PD and TSH screening

• Physical examination

• Measure OFC, BW and length

• Parent-child interaction

• Immunization schedule

Anticipatory Guidance - newborn

• Feeding method

• Sleep position and environment

• Care of skin, cord

• Breast engorgement and vaginal discharge

• Neonatal jaundice

• Postpartum adjustment of mother, siblings and family

Health Supervision at one month

• Review birth history and family history• Physical examination including growth percentile• Check for heart murmur, hip dislocation• Developmental progress: • Head to one side while supine with occasional

opening of hand• Turn head to light and startle by sudden noise• Follow movement of bright, dangling toy• Immunization schedule

Anticipatory Guidance at 1 month

• Nutrition: breast feeding/ bottle feeding

• Sleep pattern

• Social interaction with family

• Injury prevention eg. Car safety seats, hot water temperature

Health Supervision at 3 months

• History of ill health• Physical examination and growth percentiles• Developmental milestones:Head central on supine positionSupport with forearm when proneGood head control and kick wellClasp and unclasp both handsSmile in response to speechFixate on carer’s face during feeding

Anticipatory Guidance : 3 month

• Feeding

• Sleep pattern

• Social/family relationships eg. Play, cuddle baby, sibling rivalry and free time for parents

• Injury prevention eg. Car safety restraints, safe toys

• Immunization program

Health Supervision 6 months

• History and physical examination• Growth percentiles• Developmental milestones:• Reach out with both hands and transfer• Roll over and support with hand in prone

position• Bear weight on standing• Sit with support and straight back• Babbling and imitate sounds• Visually very alert

Anticipatory Guidance : 6 months

• Mixed feeding

• Stranger anxiety

• Sleep pattern

• Injury prevention eg. Discourage the use of infant walkers

• immunization

Health Supervision : 9 months

• History and physical examination Growth percentiles Developmental milestone sit alone with a straight back unsupported stand holding onto furniture crawl or shuffle on the bottoms pincer grip say single word

Anticipatory Guidance : 9 month

• Feeding and regular mealtime

• Regular bedtime routines

• Injury prevention eg. Childproof the home, avoid aspiratable food eg. Peanuts

• Immunization program

Health Supervision : 1 year old

• History and physical examination• Growth percentile• Developmental milestone:• Cruise along furniture and stand alone for

a while• Walk with one hand held• Fine pincer grip and point with index finger• Speak 2 – 6 recognisable words

Anticipatory Guidance : 1 year

• Nutrition: do not force feed

• Sleep pattern and structured bedtime routine

• Injury prevention eg. Never leave baby alone

• immunization