Urinary Tract Infection Keep in mind the possibility of UTI should be considered in any febrile child (temp >39) Girls 10^5 colony forming units of single organism /ml) or the presence of more than 1 organism Older child > 6Years will be presented by Fever vomiting Abdominal pain Dysuria Urgency Frequency Enuresis & Incontinence Most common causes gram ve colonic bacteria (E.Coli 80%) Klebsiella Proteus (more in males ) Note: Pseudomonas usually indicates structural anomaly as vesico-ureteric reflux Further investigations for ( recurrent attack or prolonged fever > 48 hours with good treatment )Abdomino-pelvic US Abdominal X-ray Micturating cystourethrography to exclude vesico-ureteric reflux Medication ( Outpatient Antibiotics choice for 7-10days )1-TMP-SFX 20mg/kg/day PO q12h

2-1st generation cephalosporins 50mg/kg/day PO q6hCephalexin or cephradine or cefadroxil3-2nd generation cephalosporins 50mg/kg/day PO q8hcefaclor

3-fluroquinolone cipro 20-30mg/kg/day PO q12h >18 years Parental therapy ( Inpatient Antibiotics choice)1-Ampicillin100-200mg/kg/day q12h I.V + Gentamicin 3mg/kg/day q12h IM Or Amikin 15mg/kg/day q12h IM2-Ceftriaxone 50-100mg/kg/day q12-24h IV Analgesics as acetaminophen & Ibuprofen Analgesics to provide relief from burning , spasticity during voidingPhenazopyridine like urisept 100mg tab (3LE) 6-12y : 1 tablet q8h after meal >12y : 1-2 tablets q8h after meal Alkalinizing agents to change the urine PH As Epimag sachets / Xenomag sachets or Coliurinal eff. Orally twice dailyFor recurrent attacks

Hematuria (Acute post streptococcal glomerulonephritis)DDxAsk about Dysuria,frequency and abdominal pain ( UTI) History of trauma Bruising (HSP) Nose bleeding (Coagulation disorders) Recent drugs (Aspirin) Vigorous ExerciseOther DDx1-Hemolytic uremic syndrome history of bloody diarrhea 2-7days before onset of renal failure edema and petechiae pallor diagnosis made upon signs of ARF + thrombocytopenia + Anaemia (stool culture E-coli)2-IgA nephropathy3-Hypercalciuria4-SLE5-Urolithiasis6-Sickle cell haemoglobinopathies7-Calculi8-Wilm`s tumor Acute post streptococcal glomerulonephritisClinical presentation of Acute post Streptococcal glomerulonephritis1-Acute nephritic syndromeOliguria and hematuria usually improved by end of the 1st weekLow grade fever ,hedacheHistory of infection 2 weeks before onset of symptomsHypertension present in >70% cases (125/80)Edema mild acute puffy eye lids & Lower limb edema 2-Hypertensive heart failure3-Hypertensive encephalopathyRenal biopsy is indicated only with persistent low C3 >3months or persistent hematuria >6monthsHome management in 95% of cases only hospitalization with severe hypertension or severe oliguria Management Rest at least 1st week (during oliguria) Diet salt & protein restriction Fluids restrictions to 1L/day Control of hypertension and edema (mild hypertension may persist for few weeks)1-Furesmide is helpful in both and increase urine ouput (1mg/kg/day q12h) 12 2-If hypertension persists add CCBlockers as Hydralazine (1mg/kg/day q12h) PO3-ACEIs effective but cause hyperkalemia Penicillin (10 days oral course for eradication of any streptococcal infection Furosemide : 1-Lasix 20,40mg ampule (2-4LE) 2-lasix 40mg tab (6LE) 3-Lafurex 20mg tab (4.5LE) 4-Lafurex 20mg ampule (1.5LE) 5-Diusex 20mg ampule (1.5LE)

Nephrotic SyndromeIt`s combination of edema, heavy proteinuria, hypoalbuminemia & hyperlipidemaWith NO hypertension or gross hematuriaInvestigationsProtein in 24 hours urine > 40mg/m2/hrSerum albumin < 3gm%Serum cholesterol > 300mg%Note : Renal function test C3 & A.S.O.T all are normalManagement : exclude active infection or other contraindications before starting Steroids therapy induction of remission ( daily therapy )Prednisone (2mg/kg/day, maximum 60mg) for 6 weeks maximum single daily dose or split into 2 dosesEither Steroid responsive : urine become free of Albumin Steroid resistant : no response after 1 month so renal biopsy indicated maintenance of remission ( alternate day therapy ) for steroid responsivePrednisone (1.5mg/kg/day, maximum 40mg) single daily dose on alternate days for 2-6 months better 6 months to decrease relapse by about 33% relapses (recurrence of edema) treated as the initial attack but alternate day therapy is continued for longer period (6-12 months)1-Hostacortin 5mg tab (4LE) 2-Hostacortin-H 5mg tab (4LE) 3-Prednisolone tab (1LE) 4-Predilon tab (2LE) 5-Deltacortil 5mg tab (1.5 LE) 6-Urbason 4mg-8mg tab (10LE) 7-Solupred 5mg-20mg tab (23-40LE)

Frequently relapsing and steroid dependant disease2 or more replases within 6 months 2 or more relapses during tapering4 or more relapses within 12 months or within 14 days of stopping steroidsBoth are steroids sensitiveCyclophosphamide e.g: Endoxan 50mg tab (38LE) Alkyloxan tab (62LE)It decrease rate of relapse compared to treatment of prednisolone Dose (2mg/kg/day) single dose for 12 weeks . alternate day therapy with prednisone is continued during the course of cyclophosphamide therapyCyclophosphamide is discontinued if WBCs count falls below 5000/cmmNote:Diuretics (furosemide) may be of benefit in childrens with edema however hypovolaemic shock occurs with aggressive treatmentAntihypertensive therapy may be used but not with Acute Renal FailureHome monitor for daily weight gain urine protein level steroid doseEnuresisRepeated involuntary voiding in childrens > 4years (expected age of bladder control)It`s either 1ry (chiled never attained bladder control) or 2ry (chiled attained bladder control for at least 6 months)It`s either Nocturnal (at night) in majority of cases with good prognosis or Diurnal (day & night) with bad prognosis Note: Urinalysis (the most important screening test in a child with enuresis) exclude U.T.IIn 2ry enuresis (5% of cases) you`ll search for a cause and manage1-Diabetes Mellitus (do Random blood sugar) 2- Diabetes Insipidus (look for urine specific gravity) 3-genitourinary anomaly ( do U/S) 4-decrease level of ADH (measure it) 5-known patient with Sickle cell anaemia 6-chronic constipation press on urinary bladderManagement of 1ry enuresis: before age of 5 years no drug treatment only 1-simple measures 3 Reassurance bladder control usually between 1-5 years Avoid excessive fluid intake 2 hours before bedtime No punishment Let child urinate before sleep Reward the baby for the dry nights Proper training such as holding urine as much as possible

2-Alarm therapy should be considered for every patient. It is reported to improve bedwetting by increasing nocturnal bladder capacity or by enhanced arousal; it does not reduce nocturnal urine output.cure rate up to 80% but relapse rate between 10-40% it gives good results after 2 weeks but it may be used upto 3 months or 1 month after being dry. If failed it should be used again once the child is older and more motivated

3-Drug therapy : it`s only indicated for children above 5 years with 1ry nocturnal enuresis1-imipramine it`s tricyclic antidepressant increase release of Anti Diuretic Hormone (theory) success rate about 60% but relapse >90%1-Tofranil 25mg tab(2.5LE) 2-tofranil 10mg tab(1.5LE) 3-imipramine 25mg tab(4.5LE) 4- toframine 25mg tab(4.5LE)Dose: start with 1 tablet daily 1 hour before sleep for 2 weeks if no response give 2 tablets (50mg) for another 2 weeks if no response stop the drug . if there`s response continue the drug for 3 months then tapering it by giving the same dose (25mg or 50mg) once every other day for 3 weeks then once every third night for 3 weeks 2 . 3 3 3 3

2-Desmopressin it`s synthetic vasopressin analogue salt retention urine concentrate decrease urine volume it`s mainly used in ttt of Diabetes Insipidus but effective in enuresis it has 50% success but relapse >94% Dose: start with minirin melt 60mcg (30tabs) (155LE) for 2 weeks if no response may increase dose upto minirin melt 120mcg (30tabs) (300LE) for another 2 weeks in case of response use the drug for 2 months then gradual tapering for 4 weeks it`s very expensive drug3-Anticholinergic drus the only benefit of these drugs it makes the bladder hold more urine but it doesn`t decrease bed time dose of oxybutynin 5mg PO daily and increased gradually up to 20mg/day at sleep time 1-uripan 5mg/5ml (7.5LE) 2-Detrusan 5mg/5ml (6.5LE) 3-Detronin 5mg/5ml (6.5LE)Some doctors use : bellacid tab (2LE) it contains belladonna 10mg & phenobarbitone 20mg for nocturnal enuresis 1/2 to 1 tablet before bed time but it`s used for spastic colon

Surgical conditions in pediatricsYou should know about it ? you will see it ? you`ll refere it Testicular Disorders undescended testisThe diagnosis of undescended testes is usually made by the parents or first examining physician. The important point is the absolute necessity of distinguishing between retractile testes and the true undescended testes. Testes that can be drawn to the scrotum, even if they retract again, are retractile testes and not undescended, the squatting position may aid in helping descend the testes for exam. Retractile testis needs no further surgical management.Time of operation ? Tell the parents that pediatrics surgeon wait until the baby reach 6 months there`s a good chance for testicular descent without surgery if this not occurred surgery must be done. Testicular swellingAny case of testicular swelling should do Testicular Ultrasonography why ? because in children it`s very difficult to differentiate Hydrocele from Inguinal hernia clinically. don`t rely on testicular size , transillumination or the size of swelling over time . moreover there may be both hernia and hydrocele together specially in preterm babies Why you do U/S ? because hernia may be incarcerated and this is surgical emergency associated with acute pain, swelling(hard-red-painful), pulling up legs and vomiting Hydrocele

A hydrocele is a collection of fluid in the space surrounding the testicle between the layers of the tunica vaginalis. Hydroceles can be scrotal, of the cord, abdominal, or a combination of the above. A hydrocele of the cord is the fluid-filled remnant of the processus vaginalis separated from the tunica vaginalis. A communicating hydrocele is one that communicates with the peritoneal cavity by way of a narrow opening into a hernial sac. Hydroceles are common in infants. Some are associated with an inguinal hernia. They are often bilateral, and like hernias, are more common on the right than the left. Most hydroceles will resolve spontaneously by 1-2 years of age. After this time, elective repair can be performed at any time Inguinal hernia is the most common surgical problem of childhood. The infant or child with an inguinal hernia generally presents with a bulge at the internal or external ring or within the scrotum. no pain is associated with a simple inguinal hernia in an infant. The parents may perceive the bulge as being painful when, in truth, it causes no discomfort to the patient. The bulge commonly occurs after crying or straining and often resolves during the night while the baby is sleeping. Inguinal hernias never go away without treatment. Furthermore, if the sac is left open, a loop of bowel or other organ may become trapped or incarcerated (strangulated) in the sac. Patients with an incarcerated hernia generally present with a tender firm mass in the inguinal canal or scrotum. The child may be fussy, unwilling to feed, and inconsolably crying. The skin overlying the bulge may be edematous, erythematous, and discolored.there`s sometimes vomiting and the baby will stop stooling This is a surgical emergency

Congenital Orthopedic Disorders in pediatrics Clubfoot (Congenital Talipes equivarus) It`s a congenital deformity of the foot that occurs in about 1 in 1,000 births. The affected foot tends to be smaller than normal, with the heel pointing downward and the forefoot turning inward. The heel cord [achilles tendon] is tight, causing the heel to be drawn up toward the leg. This position is referred to as "equinus," and it is impossible to place the foot flat on the ground. Since the condition starts in the first trimester of pregnancy, the deformity is often quite rigid at birth. The three classic signs of clubfeet are: Fixed plantar flexion (equinus) of the ankle, characterized by the drawn up position of the heel and inability to bring to foot to a plantigrade (flat) standing position. This is caused by a tight achilles tendon Adduction (varus), or turning in of the heel or hindfoot Adduction (turning under) of the forefoot and midfoot giving the foot a kidney-shaped appearance If left untreated, the deformity will not go away. It will continue to get worse over time so immediate refer to orthopaedic surgeon is required In-toeing Gait in ChildrenAn in-toeing gait is very common in children, and is a frequent complaint of many parents. In fact, an in-toeing gait (pigeon-toed) is the most common rotational deformity seen in pediatric orthopaedics. In the overwhelming majority of patients, the in-toeing will correct with growth over time.What causes an in-toeing gait in children? The three most common causes of in-toeing in children are femoral anteversion (twisting of the femur/thigh), internal/medial tibial torsion (twisted tibia/shin bone), and metatarsus adductus (curved foot). Femoral anteversion/torsionis the most frequent cause of in-toeing in children between the ages of 3-10 years. Femoral anteversion is therefore a condition in which the femoral neck leans forward with respect to the rest of the femur. This causes the lower extremity on the affected side to rotate internally (the knee and foot twists towards the midline of the body). The normal child is born with approximately 40 degrees of femoral anteversion. This will gradually decrease to 10-15 degrees at adolescence and generally improves with further growth. Femoral anteversion is more common in females, and is usually most noticeable between the ages of 4-6 years. Parents will notice that when the child is standing with the feet forward, the patellae (kneecaps) will point inwards. Frequently, parents will also describe the child's gait as awkward or clumsy. The in-toeing will often appear worse with running and at the end of the day when fatigued. Femoral anteversion will decrease naturally in 99% of cases. Internal tibial torsion It causes an in-toeing gait from a twisting of the tibia (shin bone). It is most often first noticed when a child is first starting to walk, and is most common between the ages of 2-4 years. The inward torsion is a variation of normal anatomy and is caused partially by the child's position in the uterus. The toddler or young child presents to the orthopaedic clinic with complaints of "bowing legs." Examining a child with internal tibial torsion with the patellae (kneecaps) straight, Tibial torsion almost always improves without treatment, and usually before school age. Splints, special shoes, and exercise programs do not help. Surgery to re-set the bone may be done in a child who is at least 8 to10 years old and has a severe twist that causes significant walking problems.Note: Flat FootIn the child before age 3 years, the normal longitudinal arch of the foot is present, but often masked by the fat pad in the instep. Hence all young children before age 3 look flat-footed, even though they are not. After age 3, the fat pad disappears, and the arch becomes more evident.

Metatarsus Adductus /Varus/MTAMetatarsus adductus (MTA) or varus is a condition that is commonly seen in newborns and young infants, where the forefoot is twisted inwards relative to the hindfoot (or heel). MTA is very common in the newborn, and is usually due to the feet being "packed" in the womb in that position. The forefoot adduction at this stage is very flexible, and with freedom of movement, this postural condition of MTA often improves over the next 6 to 12 weeks.In about 15% of cases, the adducted position of the forefoot does not improve. MTA that is diagnosed at birth does not require treatment. It is usually postural, and with growth, the MTA resolves spontaneously over a period of 6 to 12 weeks. X-rays are usually not necessarySevere cases of metatarsus adductus may partially resemble a clubfoot deformity.

Bowed LegsBowed legs in a toddler is very common. When a child with bowed legs stands with his or her feet together, there is a distinct space between the lower legs and knees. This may be a result of either one, or both, of the legs curving outward. Walking often exaggerates this bowed appearance.Adolescents occasionally have bowed legs. In many of these cases, the child is significantly overweight.Cause Physiologic Genu VarumIn most children under 2 years old, bowing of the legs is simply a normal variation in leg appearance. Doctors refer to this type of bowing as physiologic genu varum.In children with physiologic genu varum, the bowing begins to slowly improve at approximately 18 months of age and continues as the child grows. By ages 3 to 4, the bowing has corrected and the legs typically have a normal appearance. Blount's Disease

Left:Toddler with infantile Blount's disease involving the left leg.Right:X-ray of the left knee shows the Blount's abnormality along the top of the shinbone.Blount's disease is a condition that can occur in toddlers, as well as in adolescents. It results from an abnormality of the growth plate in the upper part of the shinbone (tibia). Growth plates are located at the ends of a child's long bones. They help determine the length and shape of the adult bone.In a child under the age of 2 years, it may be impossible to distinguish infantile Blount's disease from physiologic genu varum. By the age of 3 years, however, the bowing will worsen and an obvious problem can often be seen in an x-ray. RicketsRickets is a bone disease in children that causes bowed legs and other bone deformities. Children with rickets do not get enough calcium, phosphorus, or Vitamin D all of which are important for healthy growing bones.Nutritional rickets is unusual in developed countries because many foods, including milk products, are fortified with Vitamin D. Rickets can also be caused by a genetic abnormality that does not allow Vitamin D to be absorbed correctly. This form of rickets may be inherited (discussed later).SymptomsBowed legs are most evident when a child stands and walks. The most common symptom of bowed legs is an awkward walking pattern.Toddlers with bowed legs usually have normal coordination, and are not delayed in learning how to walk. The amount of bowing can be significant, however, and can be quite alarming to parents and family members.Turning in of the feet (intoeing) is also common in toddlers and frequently occurs in combination with bowed legs.Bowed legs do not typically cause any pain. During adolescence, however, persistent bowing can lead to discomfort in the hips, knees, and/or ankles because of the abnormal stress that the curved legs have on these joints. In addition, parents are often concerned that the child trips too frequently, particularly if intoeing is also present.Doctor ExaminationYour doctor will begin your child's evaluation with a thorough physical examination.If your child is under age 2, in good health, and has symmetrical bowing (the same amount of bowing in both legs), then your doctor will most likely tell you that no further tests are currently needed.However, if your doctor notes that one leg is more severely bowed than the other, he or she may recommend an x-ray of the lower legs. An x-ray of your child's legs in the standing position can show Blount's disease or rickets.If your child is older than 2 1/2 at the first doctor's visit and has symmetrical bowing, your doctor will most likely recommend an x-ray. The likelihood of your child having infantile Blount's disease or rickets is greater at this age. If the x-ray shows signs of rickets, your doctor will order blood tests to confirm the presence of this disorder.TreatmentNatural Progession of Disease

Physiologic genu varum nearly always spontaneously corrects itself as the child grows. This correction usually occurs by the age of 3 to 4 years.An adolescent with Blount's disease.Untreated infantile Blount's disease or untreated rickets results in progressive worsening of the bowing in later childhood and adolescence. Ultimately, these children have leg discomfort (especially the knees) due to the abnormal stresses that occur on the joints. Adolescents with Blount's disease are most likely to experience pain with the bowing.

Congenital Torticollis

It`s shortening of the cervical muscles, most commonly the sternocleidomastoid (SCM) muscle, and tilting of the head to the opposite side. Management is conservative in most cases using early physiotherapy exercises a mean duration of three months to achieve full passive neck range of motion. Those children with failed medical therapy should undergo surgical transection of the SCM muscle. Consultation with orthopedic surgery is necessary

Thyroglossal Duct Cysts

Thyroglossal duct cyst (TDC) is the most common congenital anterior midline neck mass usually (2/3 of cases) presenting before the second decade of life. Symptoms appear at an average age of four with the sudden appearance of a cystic mass at the angle of neck level moving with tongue protrusion and swallowing. Management is Sistrunk operation so immediate refer to general surgeon.