Partha’s Comprehensive Manual for Pediatric and Adolescent Practice Dhanya Dharmapalan, A Parthasarathy, Anupama S Borker, Alok Gupta, Remesh Kumar R
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdomen
plain X-ray 162
ultrasonography 79, 157, 775f
Abdominal crisis, painful 362
Abdominal pain 146, 164, 212, 282, 357, 748
pathogenesis of functional 147
severe 612
Abdominal testis, right-sided 318f
Abscess 164, 425
abdominal 613
amebic liver 812
breast 66
formation, complications of 424
hepatic 613
left lobe 813
lung 831f
multiple 813
retropharyngeal 423, 639, 640f, 641
Absolute neutrophil count 369, 518
Acanthosis nigricans 586
Acatalasemia 603
Accredited Social Health Activists 60, 790
Acellular pertussis vaccines 131
Acetabular dysplasia 469f
Acetazolamide 54
Acetic acid 135
Acetylcholinesterase 573, 783
Achondroplasia 37, 413, 578
Acid suppression 145
Acid-base
disorder 665
primary 665t
type of 665, 665t
Acidemia 636
double 668
isovaleric 593
Acid-fast bacilli 493
Acidosis
chronic metabolic 668
management of 602
Acne 516
vulgaris 441
Acneiform eruption 443
Acquired immunodeficiency syndrome 394
Acrocallosal syndrome 203
Acrodynia 93
Acro-osteolysis 510
Acute encephalitis syndrome 189
complications of 191
Acute febrile encephalopathy 101, 102
causes of 101t
Acute flaccid paralysis 176
surveillance 181
Acylcarnitine 42
Acyl-CoA oxidase deficiency 603
Acyl-coenzyme dehydrogenase deficiency, medium-chain 18, 596
Adalimumab 522
Adefovir 811
Adenitis 517
Adenoiditis 408
Adenomatoid 766
Adenosine deaminase 2, deficiency of 499
Adenotonsillectomy 579
Adenovirus 217, 458
Adolescent Health Program 59
Adolescent immunization schedule 48
Adolescent medicine 615
Adoption 795
laws 795
procedures 795
Adrenaline 267, 682
Adrenocorticotropic hormone 170, 172, 541, 542, 559
stimulation test 560t
Adrenoleukodystrophy, neonatal 603
Adriamycin 393
Advanced life support, pediatric 662
Adventitious respiratory sounds 240
Adverse drug reactions 115
Aedes aegypti 110
Aedes albopictus 110
Aerodigestive tract, upper 408
Age appropriate developmental tests 43t
Aggression, treatment of 52
Agitation 653
Agranulocytosis 368
Air leak 689f
Airway 634, 656, 664
abnormalities, central 246
compression 246
compromise, cycle of 419
congenital anomaly of 248
damage, progressive irreversible 248
disease
lower 664
reactive 760
disorders 246
foreign body 639
obstruction 264
danger signs in 694
open and support 642
opening pressure 686
wall 241
ALA dehydratase deficiency porphyria 612
Alagille syndrome 160, 161, 748
Alanine 601
aminotransferase 106, 810
Albendazole 26, 446
Albuminocytological dissociation 180
Alexander disease 203, 204
Alkaline phosphatase 301
Alkaptonuria 18
Allergen immunotherapy over pharmacotherapy, benefits of 277
Allergic conjunctivitis, seasonal 278, 466
Allergic disease 268
diagnosis of 262
Allergic rhinitis 262, 263, 276, 449, 466
clinical features of 262
prevention of 263
Allergic salute 416
Allergy 260, 261
basics of 261
All-trans retinoic acid 80
Alopecia areata 439, 440, 440f, 441f
multiple patches of 440f
Alopecia totalis 440
Alopecia universalis 440
Alpha hemolytic streptococcus 410
Alpha-blockers 314
Alpha-fetoprotein 403, 542, 573
Alpha-lipoic acid 602
Alpha-methylacyl-CoA racemase deficiency 603
Alpha-thalassemia 360
Alport syndrome 413
Alström syndrome 78
Aluminium phosphide 654656
Amblyopia 50, 453
causes of 453
management 457
prevention of 457
therapy 455
Amebiasis 812
Amebic liver 613
Amebic meningoencephalitis, primary 188
American Academy of Pediatrics 9, 214, 407
American Heart Association 209
Amikacin 5, 283
Amino acid 50, 298, 301, 601
disorders 592, 594, 597, 599, 604
metabolism
defects of 544
disorders of 547
Aminoacidopathies 602
Aminoglutethimide 535
Aminophylline 17
intravenous 639
Amiodarone 535
Ammonia 546, 591
levels 49
remove 593
Amniotic band sequence 572
Amoeba 153
Amoxicillin 105, 119, 284, 407, 459, 834, 835
Amphetamine 53
Amphotericin B 187
Ampicillin 5, 187
Amyloidosis 490
Amylophagia 347
Analgesics 377
Anaphylaxis 261, 266
Ancylostoma
braziliense 446
caninum 446
ceylonicum 446
Andersen's disease 610
Anderson-Hynes dismembered pyeloplasty 325
Androgen therapy 372
Anemia 16, 26, 37, 88, 109, 349, 360, 364, 367, 370, 382, 385, 387, 388, 780, 822f
acquired aplastic 372, 373
acute 363
aplastic 368, 369f, 385, 390
autoimmune hemolytic 349, 524
chronic hemolytic 364
congenital 375
dyserythropoietic 351
familial aplastic 368
hemolytic 353, 363, 365, 367, 386, 504, 606
hemorrhagic 386
hypoplastic 386, 390
persistent progressive 371
Anencephaly 528, 572
Aneurysm, large 213
Angelman syndrome 709
Angina, abdominal 613
Angioedema 271, 272, 274, 639
acquired 272
allergic 272
hereditary 272, 273
idiopathic 272
nonhistaminergic 272
treatment of 273
Angiomyolipomas 580
Angiotensin receptor blockers 27, 216
Angiotensin-converting enzyme 216
inhibitors 27, 297, 558
Animal blood, infected 801
Anion gap 667
normal 667
Aniridia 748
Anisocytosis 352
Anomalous pulmonary venous connection, total 229
Anophthalmia 718
Anorectal malformation 337, 774
Anorectal manometry 782
Anorexia nervosa 617, 618, 722724
Antenatal care, suggested schedule for 28
Antenatal hydronephrosis 306, 307f, 308fc, 324t
degree of 324
Anthrax 128
Antibiotic 119122, 270
drugs 600
intravenous 283
strategy 5t
topical 443
Antibody
anticardiolipin 28
cytotoxicity 261
Anticancer drugs 368
Anticholinergic 638
drug 306
Anticoagulant 655, 656
large ingestion of 656
rodenticides 654
Antidepressant, tricyclic 727
Antidiuretic hormone 304
role of 304
Antiepileptic agents 368
Antiepileptic drug 23
Antifibrinolytic drugs 377
Antigen
detection test, rapid 412
presenting cells 524
Antigliadin antibodies 275
Anti-glutamic acid decarboxylase 562
Anti-inflammatory treatment 211
Antimalarials 364
Antimicrobial prophylaxis 284
Antimicrobial resistance, role in fight against 133
Antineutrophil cytoplasmic antibody 98, 493, 494, 497, 502, 525
Antinuclear antibody 98, 158, 286, 484, 493, 505, 510, 525
Antiphospholipid antibody 526
syndrome 28, 199
Antipyretic therapy 96
Antiretroviral therapy, pediatric 64
Antirheumatic drugs
disease-modifying 486, 519t
nonbiological disease-modifying 486t
Anti-Smith antibody 505
Anti-smooth muscle antibody 158
Antistreptococcal treatment 210
Antistreptolysin O 500
Antithymocyte
globulin 372
immunoglobulin 370
Antithyroglobulin 574
Antithyroid peroxidase 574
Anti-tumor necrosis factor-alpha 521
Antiviral therapy 195
duration of 811
Antley-Bixler syndrome 585
Antral web 772
Anxiety 27, 30, 357, 545, 570, 613, 619, 624, 643, 743
disorder 48, 617, 712, 729
generalized 729
separation 729, 730
history of 707
parental 319
screening for 730
Aorta
coarctation of 574
dilated ascending 574
Aortic dissection 613
Aortic stenosis, rarely 574
Aortopulmonary window 233
Apert syndrome 253, 413, 584, 586
Apex anterior angulation 477f
Aphasia, acquired epileptic 705
Aplastic crisis 362
Apnea 171, 639
common causes of 16t
significant 16
Appendicectomy 777
Appendicitis 613
Aqueduct stenosis 576
Arcadis sustainable cities index 628
Arch cyst, second 754
Areola 45
Arginase deficiency 591
Arginine 602
glycine amidinotransferase 42
Argininosuccinate
lyase deficiency 591
synthase 1 deficiency 591
Aripiprazole 52
Aromatase inhibitors 543
Array comparative genomic hybridization 51
Arrhythmia 581, 825f
cardiac 633, 645, 656, 731
catecholamine-induced 222
Arsenic 656
Arterial blood gas 254, 634, 656, 666t
analysis 244, 666
indications of 665
disturbances, type of 667t
interpretation of 665, 666
Arthralgia 491
transient 154
Arthritis 93, 211, 483, 485, 491
causes of 483, 483fc
chronic 491
enthesitis-related 484, 485, 488, 512, 526
inflammatory 483
juvenile 480
noninflammatory 483
reactive 491
undifferentiated 484
Articulation disorder 719
Aryepiglottic folds 425
Ascariasis 166
Ascites 155, 158
Ascitic fluid 157
Ascorbic acid 364
Asexual parasitemia, presence of 108
Ash leaf spots 41
Aspartate aminotransferase 106
Asperger's syndrome 705
Aspergillus 424
Asphyxia 10, 15, 16
Aspiration
indications for 188
syndromes 246, 247
Aspirin 364
Asplenia 185
Asthenopic symptoms 457
Asthma 263, 264, 466, 678
acute 636639
exacerbation of 636
severe 243
allergic 276
atopic 264
exercise-induced 264
occupational 264
perimenstrual 264
persistent 257
related death 637
viral-induced 264
wet type 264
Ataxia 600, 601, 608, 709, 750
hereditary 609
telangiectasia 199, 390, 609
Atelectasis 678, 824
Athetoid 183
Athetosis 199
hallmarks of 199
Athyrosis 530
Atomoxetine 53, 713
Atresia
biliary 9, 156, 159, 160f
choanae 41
Atrial septal defect 229, 230, 233
Atrial shunt, right 233
Atrioventricular septal defect 233
Atropine 653
Attention deficit hyperactivity disorder 50, 53, 570, 706, 711, 743
clinical classification of 712t
Audible noises 238
Audiometry tests 716t
Auditory processing disorder 741
Auditory steady state response 716
Autism 570
red flags for 705t
spectrum disorder 50, 52, 580, 705
incidence of 705
Autoimmune
disease 27, 97, 441
disorders 490, 491
lymphoproliferative disorder 394
polyglandular syndromes 534
Autoinflammatory
disease 484
disorders 489
syndromes 490, 514, 517
Autonomic dysregulation syndrome 750
Autoregulation, loss of 633
Avascular necrosis, causes of 480
Axenfeld-Rieger syndrome 461
Axial disease 488
Azacytidine 359
Azathioprine 384, 505
Azithromycin 106, 116, 121, 210, 411, 837, 839
Azotemia 295, 297
Aztreonam 107
B
Babinski sign 182
Baby-friendly hospital initiative 62
Bacillus Calmette-Guérin 130
vaccine 114
Baclofen 198
Bacterial infection, secondary 458
Bain's circuit 672, 672f
Balanced diet, concept of 31
Balanitis xerotica obliterans 344f
Balanoposthitis 344
Baller-Gerold syndrome 585
Ballism 200
Barbie doll look 617
Bardet-Biedl syndrome 78, 317, 556, 782
Barium
carbonate 654, 656
enema 776
swallow 830f
Barker hypothesis 78
Bartonella 513
Bartter's syndrome 298, 302, 665
Basal bolus insulin initiation, principle of 563t
Basilar skull fracture 187
Baylisascaris procyonis 186
B-cell
inhibitors 521
lymphoma 395
Beare-Stevenson syndrome 586
Beckwith-Wiedemann syndrome 40, 41, 78, 400, 748, 750
Behavior disorders, disruptive 713
Behçet's disease 512, 513
Bell's scoring system, modified 780, 780t
Benzene 368
Benzylpenicillin 210
Beriberi
dry 87
infantile 88
wet 88
Beta-human chorionic gonadotropin 336, 542, 569
Bicarbonate 665
Bicuspid aortic valve 574
Bicytopenia 368
Bifid scrotum 320
Bilevel positive airway pressure 670
Biliary disease 147, 367
Biochemical tests 300
Biochemistry 541
Biologic therapies, targeted 270
Biopsy 748
endomyocardial 218
Biotin 87, 91, 602
Biotinidase deficiency, 18
Bipolar disorders 620
Birth
asphyxia 66, 183
defects 66
weight, very low 14, 69, 534
Bite cells 364
Bitot's spot 81, 82f
Black dot ringworm 438, 439
Bladder 312, 323
bowel diary 313
capacity, small 303
control 312
development of 303
contusions 329
dysfunction 310, 312
injuries 329
management 311
outlet obstruction, chronic 310
pressures, high 338
surgical treatment of 314
wall thickening 308
Blau syndrome 517
Bleeding 656
abnormal 608
disorders, signs of 416
gastrointestinal 106, 369
gums 381f
manifestations 390
per rectum 152
postoperative 321
tendency 16
Bleomycin 393
Blindness 202, 788
childhood 453
Blood 242, 362
chemistries 352
clotting 608, 610
counts 550, 634
culture 6, 13, 245, 634
grouping 29
investigations 813
loss, chronic 388
smear, peripheral 8
tests 455
transfusion 370, 375, 777
urea nitrogen 186, 329, 644
Blood glucose 545, 644
self-monitoring of 563
Blood pressure 13, 28, 292, 295, 297
discrepancy 501
high 613
low 697
monitoring, ambulatory 214
Blood sugar 79, 634
random 545
values of 11
Bloodstream triggers 696
Bloom syndrome 373, 748
Blunt injury abdomen 163
B-lymphocyte kinase 494
Bochdalek hernia 757
Body dysmorphic disorder 617
Body mass index 78, 26, 36, 226, 518, 556
Bolus insulin dose 563
Bone
avascular necrosis of 361, 361f
cysts 581
loss 475
mineral density study 358f
pain 84
Bone age 39, 529, 535, 541, 710
assessment 560
radiography 550
Bone marrow 369, 382f, 395
aspiration 373, 383, 391
smear 352f
examination 355, 375f, 382
failure syndromes 390
transplant 359
allogenic 362
Borderline personality disorder 724
Botulinum toxin 314
injection 457
Bow legs 475
Bowel bladder dysfunction 282, 305
Bowel disease, inflammatory 37, 97, 146148, 227, 526
Bowel dysfunction 312, 314
Bowel loops, distended 165f
Bowel obstruction, postoperative 777
Brachydactyly 578
Bradycardia 535, 652
suddenly developed 828f
Bradypnea 16
Brain 202
congenital malformations of 22
imaging 51
magnetic resonance imaging 79, 582
parenchyma 202
tumors 395, 396
childhood 396
Brainstem 716
evoked response audiometry 574
Branchial cleft
anomalies, second 755
fistula, second 755f
Branchial fistula, excision of 755f
Branhamella catarrhalis 406
Breast 45, 539
bud 45
engorgement 66
enlargement 552
examination 29
feeding, exclusive 62, 64
hypoplastic 66
implants 66
larger 45
milk
expressed 68
jaundice 8
pump 67, 67f
tissue 45
small amount of 45
Breastfeeding
delayed 66
nonexclusive 78
Breath 634, 656
holding spells 171
hydrogen test 275
normal 238
problems 610, 613
types of 687
volume-targeted 692f
Breathlessness 822f, 825f, 826f, 828f
chronic 828f
schoolchild with 829f
sudden onset of 827f
British Thoracic Society 672
Broad nasal bridge 41
Broad spectrum antibiotics 780
Brodsky score 253
Bromethalin 654, 656
Bronchial obstruction, classic triad of 248
Bronchiectasis 248
localized 250
Bronchiole 244
Bronchiolitis 243, 244, 678
Bronchoconstriction 652
Bronchodilator 685f
inhaled 245
therapy 692f
Bronchopneumonia 239, 826f
Bronchorrhea 652
Bronchospasm, severe 685f
Brown urine 612
Brucellosis 97
Bruckner test 452
Brudzinski's sign 185
Bruits 501
Brushfield's spots 41
Budd-Chiari syndrome 815
Bulimia 617
nervosa 723
Bunostomum phlebotomum 446
Buphthalmos 461
Buried penis 344
Burkitt lymphoma 394, 395
Burns 366
esophageal 658
upper airway 642
Button battery ingestion 658
Butyrates 359
C
Ca-caaaa-caaaat 720
Ca-ca-ca-cat 720
Café-au-lait
macules 577, 709
patches 576
spots 41, 371
Caffeine citrate 17
Calcineurin inhibitors 270
Calcium 8, 86, 293, 301, 634, 644
carbonate 85
channel blocker 216
Calmette-Guérin injection 498
Camptodactyly-arthropathy-coxa vara-pericarditis syndrome 493
Campylobacter 142
Canavan disease 203, 204
Candida 217
albicans 839
Cantonensis, angiostrongylus 186
Capital epiphysis, fragmentation of 479f
Capsulorhexis, primary posterior 455
Caput quadratum 83
Carbamates 652
Carbamazepine 54, 56, 198, 368
Carbamoyl phosphate synthetase 42, 591
Carbohydrate
diet, high 614
metabolism, disorders of 592, 594, 597, 602, 604
Carbon dioxide, end-tidal 682
Carboplatin 749
Carcinoma 538
embryonal 332, 333, 335
hepatocellular 810
Cardiac anomaly 374, 774
Cardiac arrest 656
Cardiac defects 418
Cardiac disease 664
Cardiac failure 296
congestive 678
Cardiology 208
Cardiomyopathy 608
Cardiopulmonary assessment, rapid 701b
Cardiovascular disease 216
Cardiovascular system 253
Cardioversion 222
basics of 222
Carditis 211
moderate to severe 211
Caregiver's Acts 788
Caregiver's failure 788
Carglumic acid 595
Carney syndromes 332
Carnitine acylcarnitine translocase deficiency 596
Carnitine deficiency 598
Carnitine palmitoyltransferase deficiency 596
Carotid cavernous fistula 363
Carpenter syndrome 585
Castleman's disease 521
Cat eye syndrome chromosome region 499
Catalase deficiency 603
Cataract 453
childhood 453
congenital 374, 453, 718
pediatric 453
Catastrophic antiphospholipid syndrome 523
Catch-up growth 68, 77
Cat-scratch disease 513
Cefadroxil 120, 210
Cefixime 120, 284, 837, 839
Cefotaxime 5, 283, 460
Cefpodoxie 121
Ceftazidime 460
Ceftriaxone 283
Celiac disease 37, 152, 805
clinical presentation of 805fc
Celiac human leukocyte antigen testing 807
Celiac serology 806
Cell tumors, transitional 335
Cellular functions 521
Cellulitis 476
Celphos 654
Central Adoption Resource Authority 795
Central Board of Secondary Education provisions 744
Central nervous system 79, 111, 253, 285, 286, 390, 600
disorder 16
infection 169, 633
Central venous pressure 386, 633
Cephalexin 120, 284
Cephalosporins 357
Cerebral blood flow 633
Cerebral circulation 633
Cerebral edema 633, 647
Cerebral gliomas 576
Cerebral palsy 49, 139, 181, 317, 608, 709, 711, 719, 788, 829f
Cerebral white matter migration lines 581
Cerebrospinal fluid cell count, raised 180
Cerebrovascular disease 504
Cervical
cancer 135, 136
risk factors for 135
screening 135
dermoid cyst 752
midline 756f
lymphadenopathy 392
thyroid 754
Cesarean section 66
Chandipura virus 190, 192
Chaperone therapy 606
CHARGE syndrome 413, 420, 715
Chediak-Higashi syndrome 336
Cheilosis 88, 88f
Chelation therapy 356
Chemoprophylaxis, antimicrobial 188
Chemosis 458, 466
Chemotherapy 391, 397, 398
agents 732
induction 391
preoperative 749
Chest
drain insertion 252
indrawing 16
pain 826f
radiography 767
tube, right-sided arrow 823f
ultrasound 252
wall 821
X-ray 96, 243, 759f, 820
Chickenpox 99
Chikungunya 95, 96, 99, 109, 115, 189
Child abuse 93, 379, 788
and neglect 788
types of 788
Child developed ventricular fibrillation 826f
Child growth standards 71
Child health 786t
Child Labour (Prohibition and Regulation) Act 789, 794
Child mortality rate, reducing 58
Child neglect, subgroups of 788
Child Protection System 793
Child Rights and Protection 785
Child Rights to Health 786
Child sexual abuse 790
Child Welfare Committee 794, 795
Childhood periodic syndrome 174
Children's Oncology Group 749
Chlamydia 217
trachomatis 458
Chloramphenicol 105, 116, 368
Chloroquine 364, 814, 838
phosphate 814
Choanal atresia 41, 419421
correction of 421
Cholecystitis 367, 613
Choledocholithiasis 166
Cholelithiasis 161, 367, 613
Cholestasis 79
chronic 159
first-line tests for 9t
medications for 8t
Cholesterol 291
Chordee 319
Chorea 199
treatment of 211
Choriocarcinoma 332, 333, 335, 538
nongestational 335
Chorioretinitis 8
Chromosomal analysis 50
Chromosomal anomalies 781
Chromosomal disorders 708
Chromosomal studies 370
Chronic infantile neurological cutaneous and articular syndrome 516
Chudley-McCullough syndrome 413
Chylothorax 760
Cicatricial alopecia, permanent 438
Cicatrix formation 343f
Cimetidine 614
Ciprofloxacin 284
Circulation 634, 656
Circulatory system 665
Cirrhosis
compensated 156
decompensated 156
Citrin deficiency 591
Citrulline 602
Clarithromycin 116, 210
Clean intermittent catheterization 311, 313, 339
Cleft lip 529f
Cleft palate 66, 374, 418, 529f, 720
Clindamycin 121, 411, 443
Clinodactyly 41
Clinton Health Access Initiative, Inc 124
Clitoromegaly 560
Cloaca 337
Clobazam 54, 56
Clonazepam 54, 56, 198
Clonidine 53, 198
Clostridium perfringens 366
Clotrimazole 839
Cloudy cornea 461
Cloxacillin 120, 432
Clubfoot 471
deformity, bilateral 472f
Co-amoxiclav 119, 283, 284
Cobalamin, dosage of 352
Cobblestone papillae 278
Cognitive behavior therapy 627, 708, 730, 732
Cognitive impairment, severe 576
Cohen syndrome 78
Cold 241
chain capacity, inadequate 124
chain failure vaccine vial monitors 124
intolerance 535
Collision sports 579
Coloboma 41, 420, 718
Coma 656
Comedones 443f
Communication disorder 742
Complementary food, thickness of 63f
Complete blood count 9, 96, 111, 164, 169, 283, 301, 355, 391, 408, 520, 524, 644, 748
Computed tomography 326
Concomitant chlamydia infection 459
Conduct disorder 712714
Confetti skin lesions 580, 581
Confusion 591, 613
Congenital adrenal hyperplasia 10, 18, 538, 541, 542, 559, 592, 594, 597, 599
classification of 559t
salt losing type of 560
Congenital anomaly 8, 215, 716, 718
Congenital coagulation disorders 608
Conjunctiva 462
swelling of 458
Conjunctival injection, mild 466
Conjunctival provocation test 279
Conjunctival scrape 279
Conjunctivitis 100
acute allergic 278
allergic 276, 277, 466
bacterial 459
chlamydial 459
infectious 458
neonatal 459
non-infectious 459
Connective tissue disease, mixed 524
Consanguinity 572
Consciousness, altered level of 673
Constipation 149, 312, 357, 531, 535, 557, 612
chronic 782f
functional 149, 150
habitual 784
suspect
functional 150
refractory 151
treatment of 313
Contact dermatitis, allergic 273
Continuous positive airway pressure 12, 239, 245, 651, 670
Contraception 26
Contraceptives, drug like 88
Contrast enema 776
Controlled temperature chain 124
Contusion 327, 329
Convulsive seizure, persistent generalized 633
Coombs test, direct 8, 524
Coprolalia 173
Coproporphyria, hereditary 612
Cord blood transplants 373
Cord structures, intravaginal torsion of 340f
Cornea
large 461
neovascularization of 88
Corneal clouding 82f
Corneal light reflex test 452, 457
Cornelia de Lange syndrome 146, 206
Coronary artery
abnormalities 236
disease 224
risk factors for 224, 224t
Coronavirus 178
Corporal punishment 789
Corpus callosum, agenesis of 203, 572
Cortical tubers 580, 581
Cortical visual
dysfunction 718
impairment 718
Corticosteroids 221, 383, 502
drug like 556
inhaled 245
replacement 560
Costello syndrome 400
Cotrimoxazole 105, 122
Cough 240412
acute 240
bronchiectasis 241
chronic 240
dry paroxysmal 241
evaluation of 240
persistent wet 249
postnasal drip 241
prolonged acute 240
psychogenic 241
wet 241
Counseling and motivational therapy 305
Cow's milk protein allergy 274
Coxa vara 469
Coxsackie 163
A 217
B 217
virus 178, 458
Crackles 238, 240
Craniocervical junction compression 578
Craniopharyngiomas 528
Craniosynostosis 41, 583, 585, 710
primary 584
secondary 584
Craniotabes 83, 84f
C-reactive protein 5, 6, 9, 96, 476, 483, 493, 525
Creatinine 301
Crede's maneuver 338
Cremasteric muscle contraction, abnormal 340
Cremasteric reflex
absent 341
exaggerated 316
Cri du chat syndrome 206
Crigler Najjar syndrome 7
Crimean-Congo hemorrhagic fever 111, 801
syndrome, evolution of 801, 802f
Crohn's disease 113, 349
Croup 243, 426
management of 695t
severity assessment in 641t
Crouzon syndrome 41, 253, 420, 584, 586
Cryotherapy 463
Cryptorchidism 317
Culp-Deweerd spiral flap ureteropelvioplasty 325
Cushing's disease 556, 557
Cushing's syndrome 79, 215
Cyanocobalamin 87, 90, 91
Cyanosis 12, 16, 386, 828f
reversed differential 233
Cyanotic congenital heart disease 202, 203, 229, 230, 232
classification of 229fc
Cycle bar injury 163
Cyclophosphamide 384, 393, 505, 517, 517t, 749
Cyclosporine 370, 384
A 467
Cyclotropia 456
Cyst 755
branchial 754
bronchogenic 768
choledochal 9, 166
congenital dermoid 752
cortical 308
dermoid 752
duplication 772
epidermoid 332
infected 755
simple 289
Cystadenoma 538
Cystic adenomatoid malformation, congenital 766
Cystinosis 535
Cystinuria 298
Cytogenetics 373
Cytomegalovirus 2, 9, 97, 178, 182, 186, 206, 217, 368, 415, 455, 454, 710
Cytosine arabinoside 391
D
Dacarbazine 393
Dactinomycin 749
Dactylitis 361f
Dancing eyes 172
Danon disease 611
Dapsone 364
Daunorubicin 391
D-bifunctional protein deficiency 603
Deafness 600
Deamidated gliadin peptide 806, 807
Death 647
Deep tendon reflexes, delayed 535
Defecation disorder 152
Deferasirox 357
Deferoxamine, intravenous 356
Deformity, reduction of 477
Dehydration 76, 142, 143, 647
severe 143
Dehydroepiandrosterone sulphate 541, 542
Delayed puberty 548
clinical approach to 549t
etiology of 548t
evaluation of 551fc
Delusions 591
Demyelinating disease 413
Dengue 99, 109111, 115, 368
classification of 111t
detection of 111
fever 95
management of 111t
severe 111
severity, classification of 111
shock 699, 699t
virus 190
with warning signs 111
without warning signs 111
Dennie-Morgan folds 262
Dennie-Morgan sign 445
Dental enamel pits, multiple 581
Dentition, delayed 83
Denver development screening chart 44
Denys-Drash syndrome 748
Deoxyribonucleic acid 87
anti-double stranded 505, 525
double stranded 286
Depression 48, 557, 617, 619, 631
screen for 27
Depressive disorder 743
major 731
persistent 731
screening for 732
Dermatitis
atopic 268, 273, 276, 444, 444f, 445f, 466
flexural 269f
herpetiformis 273
Dermatology 427
Dermatomyositis 273
juvenile 493, 506, 507f, 520, 526
Dermographism 274
Descemet's membrane 461
Desferrioxamine 356, 658
therapy 356
toxicity of 356
Desmopressin 306, 727
Detoxification, extracorporeal 592
Detrusor overactivity 304
Dexamethasone 384
Dextrose, addition of 546
Di Guglielmo's syndrome 351
Diabetes
mellitus 26, 28, 216, 224, 225, 509, 557, 561, 600
gestational 29
pre-existing 26
pregestational 26
Diabetic ketoacidosis 562, 564, 643, 667
management of 646fc
Diamond-Blackfan
anemia 373, 374, 374f
syndrome 368, 374f
Diaphoresis 633
Diaphragm, eventration of 760
Diaphragmatic hernia
left congenital 759f
recurrent 760
Diarrhea 212, 282, 357, 612, 652
acute 142
chronic 88
Diazepam 211
Diepoxybutane 371
Dietary modification 151, 350
Dietl's crisis 323
Digital communication 620
Dihydroxycholecalciferol 86
Diloxanide furoate 814
Dimercaptosuccinic acid 288, 310
scan 284f
Dinitrochlorobenzene 441
Diphencyprone 441
Diphtheria 58, 639
Diplopia 463
Discrete thin-walled vesicles 432f
Disruptive mood mysregulation disorder 731
Disseminated intravascular coagulation 379, 633
Distant direct ophthalmoscopy 454
District Child Protection Unit 798
Diuretic 293
renal scintigraphy 324
renography 308
Diverticulitis 613
Diverticulum 308
Dobutamine 14, 15
Donor milk banking 68
Dopamine 14, 15
agonists 198
Doppler study 341
Double blind placebo food challenges 275
Double syringe technique 67f
Down's score 4
Down's syndrome 26, 41, 160, 205, 368, 453, 567, 569, 706, 781, 831f
Doxorubicin 749
Doxycycline 116, 122
Dravet syndrome 55
Drepanocytosis 360
Drop and drip method 68
Drugs 79, 535, 633
antiprotozoal 152
antituberculous 153
fever 96
therapy 17, 372
withdrawal 592, 594, 597, 599
Dry powder inhaler and device 258
Dry scaly patch over cheeks 444f
Dual-energy X-ray absorptiometry 518
Dubin-Johnson syndrome 7
Dubowitz syndrome 373
Duchenne muscular dystrophy 566, 567
Ductopenia 161
Ductus arteriosus 227
Duhamel procedure 783
Duodenal atresia 774, 776
Duodenal web 776
Dust mite sensitization 276
Dyes 368
Dyplasia, sequale of developmental 22
Dysarthria 608, 719, 720
Dyscalculia 741
Dyselectrolytemia 15
Dysentery 119
Dysfluency, normal 720
Dysgerminoma 335, 538
Dysgraphia 740
Dyshormonogenesis 531
Dyskeratosis congenita 368, 373
Dyskinesia, paroxysmal 196
Dyslexia 739, 740, 746
Dyslipidemia 216, 224
Dysmorphism 709
Dyspepsia 147
functional 147
Dysphoria 733
Dysplasia, bronchopulmonary 16, 760
Dyspnea 249
Dyspraxia 719, 720
Dysraphism, cranial 572
Dysthymia 731
Dystonia 197
acute 198, 201
paroxysmal 198
progressive 198
Dystrophies, corneal 718
E
Ear 600
anomalies 371, 420
disease, external 414
low set 374
pain, severe 424
trauma to 425
wick, placement of medicated 424
Eating disorders 617, 618, 721, 722
Eating, healthy 617
Ebola
antibody testing 804
antigen tests 804
river 803
virus disease 803
Ebstein-Barr virus 217
Ecchymoses 8
Echocardiography 235
two-dimensional 498
Echolalia 173
Ectopic thyroid 530, 752, 754
tissue 753
Ectothrix 439
Eczema 269
atopic 444f
infantile 444
Edema 28, 290, 294
acute angioneurotic 641
allergic conjunctival 278f
conjunctival 466
idiopathic scrotal 342
intercellular 437
presence of 291
Edwards syndrome 206
Ehlers-Danlos syndrome 379
Eisenmenger's physiology 231
Elbow
extension, limitation of 578
joint 376f
septic arthritis of 478
Electrocardiography 567
Electroencephalogram 50
Electroencephalography 22, 49, 102, 170, 634
Electrolyte
disturbances, practical management of 673
imbalance 18, 76, 633
Electromyography 493, 567
Electron transferring flavoprotein deficiency 598
Electron transport chain 600
Electronic vaccine intelligence network 125
Elimination disorders 726
encopresis 726
enuresis 726
Ellis-Van Creveld syndrome 474
Eltrombopag 384
Emergency medicine 632
Emesis 653
Emotional abuse 788, 789
Emotional deprivation syndrome 528
Empathy 47
Empiric antibiotic, dose of 187
Empiric therapy 96
Empty sella syndrome 528
Empyema 250, 815, 820, 827f
thoracis 813
Encephalitidis 190t
Encephalitis 139, 189, 194t, 528, 662
acute viral 101
autoimmune 193, 201
clinical differentiation of 190t
Encephalocele 572
Encephalomyelitis, acute disseminated 191t
Encephalopathy 16, 189, 190
hepatic 193
hypoxic ischemic 22, 198
Endemic cretinism 535
Endocarditis
infective 97
postinfectious infective 298
Endocrine
development 359
disease 38
disorders 37
Endocrinology 527
Endometriosis 613
Endopyelotomy 325
Endorectal procedure 783
Endoscopy, gastrointestinal 275
Endothrix 439
Endotracheal tube 678f, 821f
expiratory 689
Energy 31
Entamoeba histolytica 812, 813
Entecavir 811
Enterocolitis 782
Enterovirus 178, 186, 458
genus 435
Enuresis 726
alarms 305
complicated 303
etiology of 303
primary 302
recurrent 306
secondary 302, 304
Enzyme
acetylcholinesterase 652
linked immunosorbent assay 84, 801
replacement therapy 606
studies 51, 604
Eosinophil predominant cell 261
Epicanthus 374
Epidermophyton 437
Epididymal fusion anomalies 340
Epididymitis 335, 342
Epiglottitis 641
acute 422, 639
risk of acute 423
Epilepsy 54, 139, 168, 170, 576
childhood absence 55
classification of 168f
juvenile
absence 55
myoclonic 55
late-onset childhood occipital 55
mimics 170
types of 171
misdiagnosis of 170
neonatal onset 22
syndrome 55
primary 169
types of 168
Epinephrine 14, 15
inhaled 245
Epiphora 461
Epiphyseal dysplasia 469, 480
Epiphysis, femoral 479
Episodes
acute hemolytic 364
stroke-like 601, 608
subsequent 210
Episodic binges 724
Epistaxis 415
treatment of recurrent 417
Epithelial cell tumors 337
Epithelial tumors
mixed 335
surface 335
Epstein-Barr virus 98, 178, 189, 368, 392
Ertapenem 284
Erythema 432f
marginatum 209
multiforme 273
Erythematous dry patches 444f, 445f
Erythroblastopenia 368
transient 375
Erythrocyte 604
sedimentation rate 98, 476, 493, 524
Erythroleukemia 351
Erythromycin 210, 432, 443
Erythropoiesis 88
ineffective 350
Erythropoietin 360
Escherichia coli 3, 131, 142, 185, 186, 282
Eslicarbazepine 54
Esophageal anastomosis 763f
Esophageal atresia 760
long gap 763
pure 760
type C 762f
Esophageal lengthening procedures 763
Esophageal pH monitoring 250
Esophageal symptoms, persistent 816
Esotropia 456
Estimated glomerular filtration rate 296
Estradiol 336
Etanercept 522
Ethambutol 113, 114
Ethosuximide 54, 56
Ethylene dicysteine 288, 308
Etoposide 391, 749
Eustachian tube 406, 408
Ewing's sarcoma 399, 400
Exanthematous illness 95
Exercise intolerance 249
Exotropia 456
Extended-spectrum-2β-lactamase, treatment of 284
Extensively drug-resistant tuberculosis 106, 112
External ear, disease affecting 413
Extracorporeal membrane oxygenation 758
Extraocular movements 457
Extraperitoneal rupture 329
Extravaginal torsion 340, 341
Extrinsic airway anomalies 246
Ex-utero intrapartum therapy 768
Eye 274, 371, 600
deviation of 457
disease, history of 452
irrigation 459
lashes, alopecia areata of 441f
misaligned 608
movement 23
rapid 306, 750
patching 459
screening, pediatric 452
signs 81
strain 457
tumor of 462
watering of 88
Eyeballs, abnormal movement of 454
Eyebrow, alopecia areata of 441f
Eyelashes, misdirected 461
Eyelid 462
F
Fabry disease 379, 453
Face mask, simple 670
Facial angiofibromas 580, 581
Facial hair growth 45
Facial plethora 394
Facial plexiform neurofibromas 576
Facial port wine hemangioma 41
Facial weakness 577
Facies, abnormal 418
Failure to thrive 594, 608, 828f
Faint 172
Fallot's physiology 230
Fallot's tetralogy, types of 228
Family planning 26
Fanconi Bickel syndrome 610
Fanconi's anemia 368, 371, 372f, 528
Fanconi's syndrome 474
Fasciculations 653
Fasciitis, eosinophilic 368
Fatigue 535
Fatty acid
beta-oxidation
disorders of medium-chain 596
disorders of short-chain 596
oxidation 596
defects 18, 544, 592, 594, 599, 602, 604
disorders 608, 611
transport, disorders of 596
Fatty liver 557
disease, nonalcoholic 156, 557
Favus 438
Febrile seizure 54, 133
simple 54
vaccine 132
type and risk of 133
Feeding
disorders 721
nasoduodenal mode of 681
plan 63
tube 763
Femoral epiphysis, slipped capital 557
Femoral head 361, 480
Fenton charts 70
Ferritin 525
Fetal alcohol syndrome 41, 206, 708, 716
Fetal heart
rate 29
sound 29
Fetal hydantoin syndrome 41, 206, 750
Fetal hydronephrosis 306
incidence of 306
Fetal lie and presentation 29
Fetal movements 29
Fetus, healthy 28
Fever 99, 100, 106, 133, 357, 825, 826f
acute 189
causes of 99t
empirical antibiotic therapy for 134
enteric 95, 97, 105, 109, 115, 119
epidemiology of 99
familial mediterranean 489, 493, 515
healthcare associated 97
hemorrhagic 111
recurrent 282
schoolchild with 829f
viruses, hemorrhagic 115
FG syndrome 203
Fibers, dietary 152
Fibrosis
cystic 18, 240, 665
tests for assessing degree of 158
Fibrous cephalic plaque 580, 581
Fistula 425, 752, 755
Flat feet 470
Flat nasal bridge 374
Flat thenar eminence 374
Flavin adenine dinucleotide 88
Flexible bronchoscopy 243, 250
Floppiness 608
Flow volume loop 256f
Fluconazole 187
Flucytosine 187
Fluency disorders 720
Fluid
administration, subsequent 645
bolus 14
cerebrospinal 6, 169, 175, 180, 185, 194, 395, 396, 601, 633
collections, acute peripancreatic 164
resuscitation 780
retention 535
Fluorescent in situ hybridization 51
Fluoroacetamide 656
Fluoxetine 52, 730
Fluvoxamine 730
Foker technique 763
Folate
ketoglutamic acid 89
supplementation 366
Foley Y-V plasty 325
Folic acid 26, 64, 87, 91, 573
antagonists 351
dosage of 352
supplementation 27, 64
Folinic acid 602
Follicle stimulating hormone 336, 541, 551, 554, 555, 574, 599
Food
allergens 274
allergy 274
fads 617
intake 563
intolerance 274
Foot disease, complications of 437
Forbes Cori disease 610
Forced vital capacity 254
Foreign body 242, 815
airway 423, 642
bronchus 426
ear 425
ingestion 815
obstruction 641
Foster care guidelines 798
Fractures 84
Fragile X mental retardation 1 570
Fragile X syndrome 41, 203, 570, 706, 709
Free erythrocyte protoporphyrin 348
Free thyroxine 533
Fresh frozen plasma 273, 657
Froin's syndrome 180
Frontal bossing 578
Frozen red cells 356
Fructose-1 phosphate aldolase deficiency 611
Fructose-1,6 diphosphatase deficiency 544
Fructose-1,6-biphosphatase deficiency 611
Fungemia 16, 18
Furosemide 218
Fusion inhibitors 521
G
Gabapentin 54, 56
Galactagogues 67
Galactose-1-phosphate uridyl transferase deficiency 611
Galactosemia 9, 18, 454, 598, 599, 611
classic 598
Gallbladder
disease 557
hydrops 212
Gallstones 161, 359, 367
incidental 162
Gamma chain production 359
Gamma-glutamyl
transferase 9
transpeptidase 160
Gangetic basin 99
Ganglion cells, absence of 783f
Gas chromatographic mass spectroscopy 51
Gastric decompression 780
Gastric lavage 652, 656
Gastric volvulus 772
Gastritis 621
ibuprofen-induced 221
Gastroenteritis 95
acute 142
Gastroenterology 141
Gastroesophageal reflux 16, 760, 772
disease 143, 144, 147, 406, 557
Gastrointestinal contrast studies 776
upper 776, 772f, 776f
Gastrointestinal endoscopy, upper 145
Gastrointestinal involvement 285
Gastrointestinal manifestations 500
Gastrointestinal symptoms 287, 312
Gastrointestinal system 274, 801
Gastrointestinal tract 212, 285, 600, 658, 815
Gastroschisis 774
Gastroscopy 807
Gaucher disease 156
Gender identity disorder 732
Gene
manipulation 359
therapy 360, 372
Genetic and metabolic testing 706t
Genetic counseling 577, 578, 580, 582, 587, 589
Genetic diagnosis, preimplantation 373
Genetic engineering 360
Genetic obesity 557
Genetic overgrowth syndromes 748
Genetic studies 567
Genetic syndromes 8, 586t, 708
Genetic testing 42, 308, 611, 807
Genital abnormalities 41, 553
Genital injuries, external 330
Genitalia, ambiguous 320
Genitourinary
abnormalities 748
anomalies 317
tract 401
trauma, pediatric 325
Gentamicin 5, 283
Genu valgum
deformity, bilateral severe 474f
nonidiopathic 474
Genu varum 578
bilateral 475f
Geophagia 347
Germ cell
sex cord stromal tumors 335
tumors 332, 335, 337, 553
benign 337
common 332
contralateral 331
familial testicular 331
mixed 335
Germinomas 528
Gerota's fat 749
Gestalt groups 627
Gestational age, large for 78
Gianotti-Crosti syndrome 437
Giant cell
astrocytoma, subependymal 580, 581
hepatitis 366
Giardia 142
Gilbert's syndrome 7
Gingival fibromas 581
Glandular tissue, inadequate 66
Glans penis 319, 345f
Glasgow coma score 108
Glaucoma 461
congenital 374, 460, 718
infantile 460
juvenile 460
primary congenital 460
secondary 461
Gliomas 528
Global developmental delay 40, 42
Glomerular disease, manifestation of 290
Glomerular filtration rate 520
Glomerulonephritis 215, 296
acute 295
postinfectious acute 294, 297
Glomerulosclerosis, focal segmental 290
Glossitis 88
Glucocorticoid 513, 517, 517t
deficiency 560
Glucose
high dose 597
infusion rate 11
monitoring 28
tolerance test 359
Glucose-6-phosphate dehydrogenase
deficiency 18, 363
estimation 365
Glutamate dehydrogenase activating mutations 544
Glutamyl transpeptidase 158
Glutaric acidemia type 1 593
Gluten free diet 805, 808
Glycogen storage
disease 156, 544, 609, 610
disorders 609
Glycoproteinoses 605
Glycosaminoglycans 42, 605
Glycosphingolipid, defects of 607
Glycosylation
congenital disorders of 607, 611
defects of multiple 607
Gnathostoma spinigerum 186
Goiter 535, 536
clinical appearance of 536f
endemic 537
Goldberg-Shprintzen syndrome 782
Goldenhar syndrome 413
Gonadal dysgenesis 331
Gonadoblastoma 333, 335, 538
Gonadotropin-producing tumors 538
Gonadotropin-releasing hormone 317, 541, 542
analog therapy 543t
Goserelin 543
Gottron's papules 507, 507f
Gout 610
Gowers’ sign 566
Granulocyte-colony stimulating factor 370
Granulomatosis 502
eosinophilic 502
Granulosa cell tumor 332, 335, 538
juvenile 332
Graphic displays, types of 683
Graves’ disease 531
Gray patch scaly ringworm 438, 439
Great arteries, transposition of 229
Greenstick fracture 477, 477f
Greig cephalopolysyndactyly syndrome 203, 586
Greulich and Pyle's atlas method 541
Growth 36, 528
and development 25
and puberty, constitutional delay of 550, 551
assessment of 32, 69, 71
tools for 71
chart 37, 72f, 73f, 74t, 557
endocrine 359
factor beta-2, transforming 494
monitoring 71
parameters for 36
parameters 40
poor 608
retardation 41, 362, 535
stages of 36
velocity 39
very slow 610
Growth hormone 68, 530, 558
bioinactive 528
deficiency 528, 529f, 556
acquired 37
congenital 37
releasing hormone receptor defect 528
stimulation test 530
Grunt 16, 239
Guanidino-acetate-N-methyltransferase 42
Guardians and Wards Act 795
Guillain-Barré syndrome 154, 176, 177, 180, 181, 192, 665
Gut injury, transfusion-related acute 777
Gymnastics 579
Gynecomastia 45, 552, 554fc, 555t
etiology of 553, 553t
management of 555, 555fc
pathophysiology of 552
H
H1N1 140
H3N2 140
Haab's striae 461
Haemophilus influenzae 128, 186, 187, 251, 406, 410, 411, 458, 460, 641
meningitis 188
type B 95, 131, 184, 422, 423, 835
Hair
line, low 374
on end appearance 355f
pull test 440
tourniquet 331
Hairy urethra 321
Hallermann-Streiff syndrome 453
Hallucinations 591, 613
Haloperidol 200
Hand
disease, complications of 437
foot
and mouth disease 99, 435, 436f
syndrome 361, 361f
small 41
trident configuration of 578
Hansen's disease 450
Hantavirus 111
Happy spitters 143
Harrison's groove 84
Hartnup's disease 89
Hashimoto's thyroiditis 531, 534, 536f
Head
and neck 41
injury 699, 716
severe 700
small 205
trauma 185
abusive 788
Headache 173, 357, 577, 621
primary 173
secondary 173
Hearing evaluation 705
Hearing impairment 715, 720
Hearing loss 357, 412, 577
neonatal 412
Heart
defect 41, 420
congenital 6, 20, 574
disease 206, 229, 233
acyanotic congenital 234
congenital 206, 228, 229, 765, 777
duct-dependent 592, 594, 597, 599
failure, congestive 387
problems 610
rate 4, 654, 682f
syndrome, hypoplastic left 233
transplant 219
Heartbeats
irregular 613
rapid 613
Heated and humidified high flow nasal cannula therapy 245
Height velocity peaks 45
Height-for-age 74
Heinz bodies 364
Heliotrope rash around eye 506f
Hemangioma 597
capillary 462
Hematemesis 660
Hematin 614
Hematochezia 660
Hematological disorder 490, 493
Hematology 346
Hematoma 327
Hematopoietic growth factors 372
Hematuria 294, 295, 323, 748
Heme
analogs 614
arginate 614
Hemidystonia 196, 197
Hemochromatosis 528
neonatal 160
Hemoglobin 29, 387, 520
C disease 363
disorders, unstable 365
low 348
S-beta thalassemia 349
Hemogram 524
complete 244
Hemolysis 364
elevated liver enzymes, low platelets syndrome 597
excessive 7
Hemolytic anemia, severe 365
Hemolytic disease 365, 366
Hemolytic disorders, inherited 8
Hemolytic uremic syndrome 286
Hemophagocytic syndrome 106, 115
Hemophilia 376, 376f, 379, 493
gene therapy 379
grades of severity of 377t
management of 377
Hemoptysis, mild 249
Hemorrhage
germinal matrix 49
intracranial 22
intraventricular 22, 464
occult internal 387
subconjunctival 459
Hemothorax 768
Henoch-Schönlein
purpura 93, 100, 147, 273, 284, 285f, 342, 492, 495
vasculitis 298
Hepatitis 212
A 47, 128, 153, 163
vaccine 128
virus 153
acute 115, 153155
viral 95, 153
autoimmune 154
B 58, 128, 130, 153, 156, 506, 521
infection 812
vaccine 27, 128, 130
virus 129, 154, 810
virus infection 809
C 156, 217, 521
chronic 97, 809, 810fc
E 153
virus 153
icteric 154f
immune-active 812
Hepatobiliary imoinodiacetic acid 160
Hepatoblastoma 403, 538
Hepatomegaly 557
Hepatopulmonary syndrome 157
Hepatorenal syndrome 157
Hepatosplenomegaly 8, 386
Hepcidin 348
Hereditary hyperinsulinism, persistent 544
Hernia 317
bilateral 757
congenital
diaphragmatic 6, 756, 768, 774
hiatal 760
diaphragmatic 759f
inguinal 320
Herpes simplex 710
encephalitis 192, 193, 193f
virus 190, 192, 217, 455
Hers’ disease 610
Hertoghi's sign 445
Heterophoria 456
Heterotaxia 774
Heterotropia 456
Hexose monophosphate 87
High arched palate 374, 570
High flow systems, classification of 670t
High inguinal orchidectomy 334f
High respiratory rate 697
High-pressure liquid chromatography method 355
Hindu Adoption and Maintenance Act 795
Hip
congenital dislocation of 469
dysplasia of 22
tuberculosis of 480
Hirschberg test 452, 457
Hirschsprung's disease 152, 750, 774, 781784
diagnosis of 783
Histoplasma 217
Histrelin 543
Hoarse cry 532
Hoarseness 412
Hodgkin's lymphoma 392
Holoprosencephaly 528
Holotranscobalamin 352
Home therapy 378
Home ventilation 678
Homocitrullinemia 42
Homocystinuria 18
Hormonal deficiencies 544
Hormone 65, 68, 553
measurement 550
study 557
therapy 575, 614
Horner's syndrome 750
Horner-Trantas dots 278, 278f
Horseshoe kidney 574
Hot water fomentation 66
Hot-potato voice 422
Hour-specific bilirubin nomogram 19f
H-type fistula ligation 764
Human chorionic gonadotropin 317, 403, 553, 555
Human herpes virus 189, 217
Human immunodeficiency virus 97, 178, 189, 227, 368
Human leukocyte antigen 370, 484, 526, 806, 807
Human milk banking 62
Human papilloma virus 27, 129, 135
vaccine 135, 136
Human seasonal influenza 139
Human-to-human transmission 801, 803
risk of 803
Huntington's disease 199
Hydrocele 317
Hydrocephalus 40, 204, 204f, 205
Hydronephrosis 306, 307, 322, 325
postnatal 309fc
evaluation of 309fc
transient 307
Hydrops 13
Hydroureteronephrosis 325
Hydroxychloroquine 486, 505, 559
Hydroxyprogesterone 541, 542
Hydroxyquinoline preparations 445
Hydroxyurea 360, 362
Hyoid bone, part of 753
Hyper IgD syndrome 493
Hyperaldosteronism 665
primary 215
Hyperammonemia 42, 591
Hyperbilirubinemia 7, 7t, 364, 365, 771
conjugated 367
direct 7, 8
indirect 7, 8
prolonged 7
unconjugated 367, 386
Hypercalcemia 163
Hypercalciuria 298
Hypercarbia 633
Hypercholesteremia, familial 224
Hyperechogenicity 323
Hyperekplexia 171
Hyperglycemia 633, 636, 643
ketotic 544
Hyperimmunoglobulinemia D 515
Hyperinsulinemia, primary 10
Hyperinsulinism 544
factitious 544
hyperammonemia syndrome 544
Hyperkalemia 296, 676
management of 677fc
Hyperkeratosis 81
Hyperlipidemia 290
Hyperlipoproteinemia 611
Hypermobility syndromes 474
Hypernatremia 602, 675
management of 675fc
Hyperornithinemia 42
Hyperostosis cranii 202
Hyperoxaluria 298, 603
Hyperparasitemia 108
Hyperphosphatemia 656
Hyperplasia, areolar 45
Hyperpyrexia 209
Hypersensitivity
cellular 261
delayed 261
Hypersomnia 724
Hypersplenism 357
Hypertelorism 41, 374
Hypertension 28, 214, 214t, 224, 225, 229, 294297, 501, 511, 557, 633, 748
diagnosis of 214
management of 502
pre-existing 27
secondary 215t
Hyperthermia 16, 633
Hyperthyroidism 215, 554
Hypertonia 16
Hypertonic saline nebulization, inhaled 245
Hypertriglyceridemia 163
Hypertrophy, adenoid 408, 410
Hypertropia 456
Hypoalbuminemia 290, 804
Hypocalcemia 16, 18, 22, 294, 418, 454, 639
Hypochondriasis 621
Hypocitraturia 298
Hypoglycemia 6, 9, 10, 15, 16, 18, 22, 76, 108, 454, 544, 546fc, 563, 633, 636, 804
autoimmune 544
Hypogonadism 41, 371
hypergonadotrophic 553
hypogonadotropic 548, 549, 553
Hypokalemia 656, 675
causes of 676fc
management of 676, 676fc
Hypolipidemic agents 558
Hypomagnesemia 22
Hypomelanotic macules 580, 581
Hyponatremia 22, 673, 674fc
factitious 674
management of 674fc
Hypophysitis 528
Hypopituitarism 9, 528, 531, 535
Hypoplasia 530
genital 420
Hypoplastic thumb 374
Hypospadias 319, 529f
anterior 319, 321
distal 322
posterior 321
proximal 320
repair 320
treatment of 321
types of 320
Hypotelorism 41
Hypotension 14, 165, 633, 828f
Hypothalamic dysfunction 750
Hypothermia 16, 76, 532, 535, 545
Hypothyroidism 26, 30, 66, 353, 549, 556, 708
acquired 534
central 537
chronic primary 538
congenital 8, 9, 18, 37, 79, 530, 531f, 533fc
consumptive 537
etiologies of 536f
juvenile acquired 534
laboratory function in 537t
peripheral 535
primary 534, 537
secondary 535
Hypotonia 16, 568, 594, 608
Hypotropia 456
Hypoventilation 750
central 678
congenital central 782
Hypoxemia 636
mild 633
Hypoxia 16, 18, 633, 825f
Hysteresis 690, 691f
I
Ichthammol glycerine 424
Ichthyosis vulgaris 445
Icterus 16
Idiopathic hypercalciuria, primary 298
Idiopathic nephrotic syndrome, primary 290
Idiopathic thrombocytopenic purpura 93, 380
Imipenem 284
Imipramine 306
Immune
complex reaction 261
deficiency 826f
hemolytic anemias 366
paralysis 131
system 248
thrombocytopenic purpura 380
classification of 380t
Immunity, impaired cellular 187
Immunization 123, 158
attitudes, types of parental 126
during pregnancy 127
parental perceptions about 126t
technical support unit 125
Immunofluorescence 801
Immunoglobulin
E 466
G 158
nephropathy 298
prophylaxis 837
Immunology 260
Immunomodulation therapy 370
Immunotherapy 372
allergen-specific 276
Impaired hypothalamopituitary axis 548
Impalpable testis, left 318f
Impetigo 432
contagiosa 432f
In vitro
fertilization 760j
tests 279
Indian Academy of Pediatrics 48, 556
Indian Academy of Pediatrics Growth Charts 617
revised 64, 71
Indomethacin 368
Infancy, septic hip of 469
Infant and young child
feeding 62, 64
nutrition 30
Infant milk substitutes Act 62
Infections 9, 16, 22, 62, 76, 156, 248, 321, 362, 370, 480
acute 411
bacterial 115, 282, 357
congenital 206, 708, 716
episodic exacerbations of 249
fungal 424
prevention of 350
practices for 6t
Infectious agents, specific 178
Infectious disease 94, 118, 732
vector of 430
Inflammation
acute 244
chronic pericardial 219
Inflammatory disease, pediatric 523
Inflection points
lower 691f
upper 691f
Infliximab 522
Influenza 28, 193
complications of 139
vaccination 139
limitations of 140
vaccine
inactivated 128
types of 139
Infradiaphragmatic disease 392
Inguinal testis, right 318f
Inhalation therapy 257
Inhaled medication delivery 258
Inherited pyrimidine synthesis disorders 351
Iniencephaly 572
Inner ear, disease affecting 413
Insect bite hypersensitivity 429
Insecticides 368
Insomnia 52
behavioral 725
Insulin
calculation 563
infusion 645
like growth factor 1 79
therapy, initiation of 562
Insulinoma 544
Integrated Child Development Services Scheme 787
Integrated Disease Surveillance Programme 59
Intellectual disability 706, 708
classification of 709t
signs of 709t
symptoms of 709t
Intensive care 661
unit 111
Interleukin inhibitors 521
Interleukin-1 receptor antagonist, deficiency of 516
International Agency for Research on Cancer 135
International Children's Continence Society 302
International Classification of Retinopathy of Prematurity, revised 21
International League Against Epilepsy 168
International League of Associations for Rheumatology 489
International Neuroblastoma Staging System 751
International Society for Pediatric Oncology 749
Interpersonal therapy 732
Interrupted aortic arch syndrome 233
Intersex 549
Interstitial lung disease 144, 510, 511
Intestinal motility disorders 613, 784
Intoxication 633
Intracranial pressure 102, 396, 579
Intralobar sequestration 769
Intraocular lens 455
Intraocular pressure 518
Intraperitoneal rupture 329
Intrauterine growth
deficiency 38
restriction 8, 27, 69, 78
Intrauterine infection 8, 22
Intravenous fluid 645, 813
titration of 675t
Intravenous immunoglobulin 5, 98, 219, 518, 522
composition of 522
Intrinsic airway anomalies 247
Intussusception 137
Invasive ventilation 677
Iodine 535
deficiency 535, 537
Iodoquinol 814
Ipratropium 682
Iris hamartomas 575
Iron 31, 64, 79
binding capacity, total 348
deficiency 347
anemia 347, 348, 348f, 360
causes of 347
folic acid 29
poisoning 657
prophylaxis 29
supplementation 64, 350
therapy 29
parenteral 349
Irradiation 528, 535
Irritability, treatment of 52
Irritable bowel syndrome 147
Ischemia, acute mesenteric 613
Isolated growth hormone deficiency 528
Isolated thyroid stimulating hormone deficiency 531, 535
Isoleucine 593
Isoniazid 113, 114
Itching sensation 424
Itraconazole 187
J
Jackson-Weiss syndrome 586
Janani Sishu Suraksha Karyakram 58
Janani Suraksha Yojana 58
Japanese encephalitis 101, 192, 201
survivors, rehabilitation of 138
vaccination 138
vaccine 138, 195
virus 189
Jaundice 7, 28, 108, 159f, 365, 813
absence of 386
pallor without 386
prolonged 531
Jejunal atresia 774
Jervell and Lange-Nielsen syndrome 413
Jitteriness 23, 171
Joint 285
contractures 608
hypermobile 470
Joubert syndrome 572
Jugular venous pressure 230
Juvenile idiopathic arthritis 227, 484, 486t, 490, 491t, 520
diagnosis of 484
management of 486
oligoarticular 487
mimickers of 490
ophthalmological screening in 514t
subtype of 485t, 512t
Juvenile Justice (Care and Protection of Children) Act 789, 793
Juvenile Justice Board 794
Juvenile rheumatoid arthritis, systemic onset 97
K
Kala azar 97
Kasabach-Merritt syndrome 386, 462
Kaufman-McKusick syndrome 782
Kawasaki disease 97, 98, 100, 115, 211, 489, 492, 494, 495, 497, 498, 521, 523, 524
atypical 213, 498
complete 498
diagnosis of 498, 498b
resistant 499
Kearns-Sayre syndrome 601
Keratitis 88
Keratoconjunctivitis, atopic 466, 467
Kerion 438, 439
Kernig's sign 177, 185
Kerosene 650
ingestion 650, 651
poisoning 650
Ketamine infusion 635
Ketogenesis defects 596
Ketosis 643
Kidney 285287, 510, 600
biopsy, indications for 297
disease
chronic 216, 305, 310, 668
underlying 306
ectopic 372f
function tests 750
injury, acute 310, 645
problems 610
single unilateral 574
Kikuchi disease 113
Kimura's extrathoracic elongation 763
Kinesigenic choreoathetosis 196
Kiss knee test 177
Klebsiella pneumoniae 3, 251
Kleine-Levin syndrome 724
Klinefelter syndrome 553, 708
Klippel-Feil deformity 374
Knee joint 376f
Knock knee 473
Knuckle
hyperpigmentation of 351f
pigmentation 90f
Koebner's phenomenon 434
Kolpik's spots 100
Krabbe's disease 204
Kyasanur Forest disease 189
Kyphosis 579
L
Laceration 327
Lacosamide 54
Lacrimation 653
Lactate dehydrogenase 336, 555
Lactation 86
Lactation failure 65
partial 65
total 65
Lactation insufficiency
primary 66
secondary 66
Lactational failure 66
Lactic acidosis 601, 633, 667
congenital 611
Lactogenesis, stages of 65
Lactose intolerance 66
Ladd's bands, release of 777
Ladd's procedure 777f
Lamivudine 811
Lamotrigine 54, 56
Landau-Kleffner syndrome 56, 705
Langerhans cell histiocytosis 97, 476
Language evaluation scale Trivandrum 44
Laparoscopy 318f
Laparotomy, indications for 328
Larva migrans 447f
cutaneous 446, 447f
Laryngeal cartilage 425
Laryngeal diphtheria 423
Laryngeal papilloma 639
Laryngeal web 418
Laryngitis, chronic 144
Laryngomalacia 425
Laryngoscopy, direct 642
Laryngotracheobronchitis 426
acute 639, 640, 642
Laxatives 152
L-dopa 364
Lead nephropathy 360
Lead poisoning 349, 613, 824f
Learning disability 712, 737, 738, 741, 743, 746
specific 738
tests for specific 743
types of 740
Learning disorder 738
Leber's hereditary optic neuropathy 600, 601
Leflunomide 486, 487
Left ventricular hypertrophy 558
Leg
bowing of 84, 84f
deformities 475
ulcers 359
Legg-Calve-Perthes disease 363
Leigh encephalomyelopathy 88
Leigh syndrome 600, 601
Lennox-Gestaut syndrome 56
Lens aspiration 455
Leptospirosis 95, 109
Lesch-Nyhan syndrome 201
Lesion
duct-dependent 228
obstructive 233, 236
persistence of 450
space-occupying 716
Let-down reflex 65
Lethal meningococcal disease 185
Lethargy 535, 656
Leucine 593
Leukemia 332, 385, 390, 576
acute 353
childhood 391
lymphoblastic 369, 390, 391
myeloid 369, 373, 390, 391
treatment of 392
Leukocoria 454, 462
Leukocyte
concentration of ascorbic acid 93
count 382
esterase, positive 283
Leukocytoclastic vasculitis 494
Leukocytosis 633
Leukomalacia, periventricular 49
Leukopenia 504
Leukotriene receptor antagonists 263
Leuprolide 542, 543
Levetiracetam 54, 56
Levothyroxine 534
Lewis’ disease 609
Leydig cell 332, 538
tumor 332
Lichen scleroses 793
Li-Fraumeni syndrome 390, 400
Ligation probe analysis, multiple 560
Light-house sign 407
Limbs 528
Lingual thyroid 530, 754
Lipodystrophy 507
Lipomasia 552
Liquid nitrogen spray 446
Lisch nodules 41, 575, 576
Listeria 186, 217
monocytogenes 185
Lithium 535
Livaditis circular myotomy 763
Live-attenuated influenza vaccine 129
Liver 212
biochemical tests of 157
disease 88, 155, 353, 416, 417, 608
acute 154
chronic 154, 155, 157, 418
decompensated 158
end-stage 155, 156, 159, 310, 503, 515
inherited metabolic 156
pediatric end-stage 158
symptoms of 155
enzymes, elevated 608
function 748
test 520, 656
iron concentration 355
transplant 158
Lobar emphysema, congenital 765, 766f, 768
Lobectomy 766
Long chain fatty acid beta-oxidation, disorders of 596
Lorenzo's oil 605
Low birth weight 66, 68, 79, 130, 534
Low fertility 317
Low flow systems, classification of 670t
Lowe syndrome 202f, 453
Löwenstein-Jensen media 113
Lumbar puncture 186, 634
Lumbar scoliosis 481f
Lumbosacral dermal sinus 185
Luminal agents 814
Luminal myofibroblastic proliferation 212
Lung 212
agenesis, primary 760
congenital cystic disease of 760
disease, chronic 760
lesions, congenital 765
parenchyma 249
tissue, normal 769
Lupus anticoagulant 28
Luteinizing hormone 336, 541, 542, 551, 554, 555
Lyme disease 512, 513
Lymph node
biopsy 392
disease 113
mass 394
Lymphadenopathy 431f
Lymphangioleiomyomatosis 581
Lymphatic tissue 408
Lymphoblastic lymphoma 395
Lymphocytes 406
Lymphocytic pleocytosis 193
Lymphohistiocytosis, hemophagocytic 97, 156, 525
Lymphoma 97, 113, 332, 385
cells 395
Lymphoreticular malignancies 606
Lysosomal disorders 605
Lysosomal storage disorders 605
Lysosome-associated membrane protein 2 deficiency 611
M
Macrocephaly 40, 202, 202f, 578
benign familial 205
Macrocytes 352
Macrocytic anemia 350
Macrocytosis 351
Macroglossia 41, 532
Macro-orchidism 41
after puberty 570
Macrophage activation syndrome 490, 504, 523, 525
Macular rash 99
Maculopapular rash 99
Madras Dyslexia Association 746
Maffucci syndrome 336
Magnesium 301, 634, 644
intravenous 639
sulphate, antepartum 16
Magnetic resonance
spectroscopy 601
tomography 493
Maharashtra Dyslexia Association 746
Mahila Arogya Samities 60
Malaria 9, 95, 97, 107, 109, 115, 153, 385
antigen test, rapid 96, 108
severe 108t, 109
therapy of 109t
Malarial parasite 634
Malformation 6, 49
Malin's intelligence scale 44
Malnutrition 74
acute 75
chronic 75
moderate acute 75
severe acute 75, 81, 137
spectrum of 75
Malrotation 774
intestinal 773
Mammary gland 552
Mandibular hypoplasia 253
Mania 27
Maple syrup urine disease 18, 544
Marker X syndrome 570
Marsh grading system, modified 808
Martin-Bell
phenotype 570
syndrome 570
Mask, simple 671f
Mass spectrometry 594
Massive intraventricular hemorrhage 16
Massive proteinuria 290, 291
Mast cell
predominance 261
tryptase 275
Mastectomy 66
Mastoiditis 97
Masturbation 172
Maternal and child health services 58
Maternal antiretroviral therapy 64
Maternal health 58
Maternal mortality rate, reducing 58
Maternal phenylketonuria 41
Maxillary sinusitis 187f
McArdle's disease 610
McCune-Albright syndrome 538, 542, 543
Mean corpuscular
hemoglobin concentration 352, 367
volume 348
Mean platelet volume 369, 382
Measles 58, 81, 115
elimination 47
mumps, and rubella 27
vaccine 129
pertussis, tetanus, diphtheria 47
virus 190
Meatal stenosis 321
Mechanical breath 686f
Mechanical ventilation 639
Meckel's diverticulum 774
Meconium aspiration 6
Mediastinal lymphadenopathy 392
Mediastinal tumors 243
Medicolegal aspects 789
Medicolegal status 797
Megaloblastic anemia 90, 350, 351, 351f, 369
Megaloblastic crisis 361, 362
Megaloblasts 352f
Megalocornea 461
Mega-prepuce 344
Megaureters 307
MELAS syndrome 601
Melatonin 53
Menarche 45, 557
age 543
Meningiomas 528
Meningitis 22, 95, 97, 184, 188, 528, 662, 708
acute bacterial 101
bacterial 113, 186
benign recurrent 192
fungal 187
recurrent 187f
repeated episodes of 188
Meningococcal
bacteremia 95
polysaccharides 129
vaccine 128, 129, 189
Meningococcemia 155
Meningoencephalitis 115, 435
Meningomyelocele 204f, 337, 572
Mental changes 613
Mental disorder 704, 742
Mental health 30, 48
Mental retardation 317, 420, 568, 748, 788
Mental subnormality 371
Meropenem 284
Mesenteric cyst 774
Mesocolic hernia 777
Messenger ribonucleic acid 589
Metabolic acidosis 228, 643, 665, 667, 668
Metabolic alkalosis 665, 667
Metabolic decompensation, treatment of 594
Metabolic disease 461, 633
Metabolic disorder 8, 205, 590
Metabolic disturbances 169
Metabolic function, monitoring 595
Metabolic screening 634
sampling for 18t
Metabolic syndrome 224, 226, 557
Metabolic tests 204
Metabolism, inborn error of 6, 16, 18, 633, 667, 708
Metacarpophalangeal joints, hyperextensible 570
Metaiodobenzylguanidine 751
Metallic phosphides 655
Metaphyseal dysplasia 475
Metaplasia, keratinizing 81
Metastatectomy 749
Metastatic disease 402
distant 401
Metatarsus adductus 472
Metformin 67, 558
Methemoglobinemia 365
Methicillin-resistant staphylococcus aureus 105
Methimazole 535
Methionine synthase gene, inborn genetic mutations of 351
Methotrexate 486, 487, 505, 511
Methylcrotonylglycinuria 593
Methylenetetrahydrofolate reductase 42
Methylmalonic acidemia 544, 593, 595
Methylphenidate 52, 53, 713
Methylprednisolone 370, 505
high dose 383
Metoclopramide 67
Metronidazole 122, 460, 814
Mevalonate kinase 515
Meyerson's eczema 434f
Microcephaly 40, 205, 371, 374, 829f
Microcytic anemias 349
Micro-erythrocyte sedimentation rate 6
Micrognathia 41, 374
Micronutrient deficiencies 77
Microphthalmia 718
Microspherocytes lacking central pallor 367f
Microsporum 437
audouinii 438, 439
canis 438, 439
Microstomia 510
Micturating cystourethrogram 338
Micturating cystourethrography 284f, 324
Midazolam infusion 635
Middle ear 185
disease 414
affecting 413
dysfunction 579
Midface
hypoplasia 41, 253
retrusion 578
Midline defects 528
Midstream clean catch 283
Migraine 173
abdominal 174
atypical 174
with aura 174
without aura 173
Milk
ejection 65
inadequacy of 65
production reflex 65
substitution of 68
Miller-Fisher syndrome 177
Milrinone 14, 15
Mineralocorticoid replacement 561
Ministry of Women and Child Development 788
Miosis 652
Miscarriages, recurrent 28
Mission Indradhanush 59
Mitigate allergic diseases 267
Mitochondrial diseases 601
Mitochondrial disorders 183, 592, 594, 597, 599601, 604
Mitochondrial DNA depletion syndrome 601, 611
Mitochondrial encephalomyopathy 601
Mitochondrial fatty acid 2β-oxidation disorders 596
Mitochondrial myopathy 600, 611
Mitomycin C 371
Mitral valve prolapse 571, 574
Mitrofanoff appendicovesicostomy 339
Mitrofanoff procedure 314
Mixed disturbances, type of 668
Moisturizers 270
Molecular genetic testing 204
Molluscum
bodies 435
contagiosum 434, 434f, 435f
Monocytopenia 368
Monogenic autoinflammatory disorders 515
Monogenic disorders 78
Monogenic polyarteritis nodosa 499
Mononucleosis, infectious 97
Monosomy 368
Monosymptomatic enuresis 303
Monotherapy 56
Monteggia lesion 477
Mood disorders 620, 729, 731
Moraxella catarrhalis 409, 835
Morgagni hernia 757, 831
Morphea 508
Mortality rate, reducing infant 58
Mother's Absolute Affection Program 58, 62
Mouth
disease, complications of 437
movement 23
sores 610
Movement disorders 195
discussion of 197
type of 196fc
Moyamoya disease 199
Mucinous tumors 335
Mucociliary clearance disorders 246, 247
Mucopolysaccharides, urine screening for 51
Mucopolysaccharidosis 51, 605
Mucosal vaccines 131
Mucus-secreting epithelium 406
Muenke syndrome 586
Multicystic dysplastic kidney 288, 307
Multidrug-resistant tuberculosis 112
Multifactorial autoinflammatory syndromes 517
Multifocal micronodular pneumonocyte hyperplasia 581
Multiorgan failure 634
Multiorgan inflammatory disease 209
Multiple organ dysfunction syndrome 645
Multiplex ligation-dependent probe amplification 51
Multisystem inflammatory disease, neonatal-onset 489, 493, 516
Mumps 163, 368
orchitis 342
virus 190
Murmur 16
Muscle
biopsy 567
cardiac 600
disorders, congenital 608
enzymes 526
pain 612
pseudohypertrophy 535
rigidity 656
tone, low 608
weakness 653
proximal 84
Muscular dystrophies 611
Musculoskeletal stress 557
Mutation analysis 604
Mutism, selective 706, 707
Muzaffarpur encephalopathy 191
Mycobacterium 217
bovis 130
tuberculosis 98, 112, 251
Mycophenolate mofetil 505, 511
Mycoplasma 217, 285, 410
pneumoniae 178, 251, 835
Mydriasis 633
Myelitis
acute transverse 178
transverse 176, 181, 338
Myelocele 572
Myelodysplastic syndrome 369, 373, 385, 390
Myelofibrosis, primary 369
Myeloma, multiple 369
Myelophthisic anemia 385
Myenteric plexus 783f
Myocarditis 139, 154, 217, 435
Myoclonic epilepsy 580, 601
Myoclonus 750
Myoglobinuria 634
Myoneurogenic gastrointestinal encephalopathy 601
Myringitis
acute 425
chronic 425
N
N-acetyl cysteine 647
dosage regimens 649
N-acetylglutamate synthase deficiency 591
N-acetyl-P-benzoquinone imine 647
Nail
changes 440
dystrophy 440f
Nailfold capillaroscopy 510, 511
Nairovirus 801
Narcotics 732
Nasal continuous positive airway pressure 679f
Nasal mucosal biopsy 250
Nasal prongs 670, 679f
Nasal septum, part of 416
Nasoduodenal tube 681
Nasogastric tube 77, 634
Nasolabial dyssebacia 88
Nasopharyngeal neoplasm 409
National Consultative Group 32
National Health Mission 57
National Health Programs for Growth and Development Monitoring 57
National Immunization Program 125
National Institute for Open Schooling 744
National Institute of Health 576
National Nutritional Anemia Control Program 350
National Rural Health Mission 57
National Study on Child Abuse 790
National Tuberculosis Control Program, revised 113
National Urban Health Mission 57, 59
Natural killer cell 488
Nausea 357, 545, 612
Necator americanus 446
Neck
cyst 752
lateral 754
flexor 507
muscle weakness 566
ultrasound 752, 753, 754
webbed 41, 374
Necrosis, intestinal 645
Necrotizing arteritis 212
Necrotizing enterocolitis 2, 16, 62, 777
Neisseria
gonorrhoeae 458, 459, 496
meningitidis 184
Neonatal cholestasis 7
syndrome 159
causes of 159
Neonatal immunization 130, 132
hypothesis for 130
Neonatal intensive care unit 62
Neonatal jaundice 364
screen 19
Neonatal sleep myoclonus, benign 171
Nephritic syndrome 294
causes of acute 298
Nephritis 154
Nephrolithiasis 323
Nephrology 281
Nephrostomy 311
Nephrotic syndrome 290, 296
congenital 290
idiopathic 290
secondary 290
Nephroureterectomy, unilateral 749
Nerve
fibers, hypertrophied 783f
peripheral 600
Neural tube defects 26, 571
Neuroblastoma 749, 750
high-risk 752
intermediate-risk 751
intra-abdominal 750f
low-risk 751
Neurocristopathy syndromes 782
Neurocutaneous disorders 203
Neurodegenerative disorders 716
Neurodevelopmental disorder 49, 52, 704
Neurodevelopmental screening tool 44
Neurofibromas 575
cutaneous 576
Neurofibromatosis 41, 390, 575, 577, 709, 750
syndrome 413
Neurogenic bladder 337
Neuroglycopenic symptoms 545
Neurologic deficits 189
Neurologic syndrome 653
Neurological disease 145
Neurological system 665
Neurology 167
Neuromuscular diseases 472, 475, 678
Neuromuscular scoliosis 608
Neuronal ceroid lipofuscinosis 51
Neuropathy 600, 601
acute motor axonal 177
cranial 656
Neurosonogram 3, 204
Neurotrophins, levels of 770
Neurovisceral sphingolipidosis 611
Neutral protein Hagedorn 563
Neutropenia 369
Neutropenic infections 392
Newborn 1
hearing screen 21
screening 18
with cyanosis 829f
Next generation sequencing 51
N-glycosylation, disorders of 607
Niacin 87, 89, 91, 602
Nicotinamide adenine dinucleotide phosphate 87
Nicotinic symptoms 653
Niemann pick disease 156, 611
Night expressing 67
Night feeding 67
Nipah virus 189, 190, 192
Nipple stimulation 67
Nitazoxanide 814
Nitrazepam 54
Nitrofurans 364
Nitrofurantoin 284, 364
Nitrous oxide 351
N-methyl-D-aspartate 101
Nocturnal emissions 45
Nocturnal enuresis 302
Nocturnal hemoglobinuria, paroxysmal 368, 369
Nocturnal itching, absence of 448
Nocturnal polyuria 304
Nodular scabies lesions 428f
Nomophobia 625
Nonepileptic paroxysmal disorders 170
Non-Hodgkin's lymphoma 369, 394, 395, 409
Noninflammatory arthropathy disorders 493
Noninvasive positive pressure ventilation 17, 639
Noninvasive ventilation 651, 677, 678f, 681f, 682
complications of 681b
indications of 678, 678b
Nonmonosymptomatic enuresis 303
Non-neurocristopathy syndromes 782
Non-offensive smell 242
Nonrebreathing mask 671, 671f
Nonrenal hamartomas 581
Nonscarring alopecia 504
Nonsick baby 2
Nonsteroidal anti-inflammatory drugs 221, 377, 407, 477, 486, 486t, 517t, 813
Nonsyndromic mutations 708
Nontuberculous mycobacterial infections 113
Nonviral infections 178
Norepinephrine 14, 15
Norrie disease 453
Novel therapies 362
Nucleic acid tests 804
Nucleoside analogs 809
Nucleotide polymorphisms, single 494
Nutrition 61
adolescent 47
healthy 30
parenteral 780
Nutritional deficiency, primary 38
Nutritional disorders 61
Nutritional obesity 556
Nutritional rehabilitation centers 59
Nutritional rickets, treatment of 85t
Nutritional supplementation 388
Nystagmus 50, 454
O
Obesity 40, 224, 226, 559, 610
childhood 556
complications of 558
etiology of 556t
evaluation, screening tests in 558t
hypothalamic 556
hypoventilation syndrome 557
infantile 78
pharmacotherapy of 558t
rapid-onset 750
Obsessive-compulsive disorder 48, 625, 730
Obstructed venous return-inadequate perfusion 757
Obstruction 660
biliary 367
colonic 613
complete 642
incomplete 642
intestinal 6
Obstructive shock 13, 15, 664
Obstructive sleep apnea 253, 557, 578, 678
persistence of 254
recurrence of 254
syndrome 253
Obstructive sleep disordered breathing 253
Occult fracture 478
Occupational therapy 796
Ocular disease, inherited 452
Ofloxacin 284
Oligoarthritis 484, 512
asymmetric 491
Oligosaccharides 128
urine screening for 51
Oligosaccharidosis 605
Ollier disease 336
Omphalocele 774
Oncology 389
Oncovin 393
Ophthalmology 451
Ophthalmoplegia, chronic progressive external 601
Ophthalmoscopy, indirect 463
Opisthotonus 656
Opitz trigonencephaly syndrome 586
Oppositional defiant disorder 712, 713, 743
Opsoclonus-Myoclonus syndrome 172, 750
Optic atrophy 50
Optic disc 463
Optic glioma 575
Optic nerve, evaluation of 461
Optic pathway glioma 576
Optimal body weight management 26
Oral amoxicillin 411
Oral anatomical anomalies 720
Oral antibiotics 284, 407
Oral desmopressin 306
Oral iron therapy 348, 349, 388
side effects of 349
Oral phenobarbitone 211
Oral poliovirus vaccine 130
Oral rehydration solution 142
Oral thrush 825f, 826f
Oral ulcers 412, 504
Orbit, tumor of 462
Orbital cellulitis 459, 460
Orchitis 335
Organ
dysfunction 696
periodic tests for 355
endocrine 600
involvement 495t
specific injuries 326
Organic acidemia 592594, 597, 599, 602, 604
Organic acidurias 608, 611
Organic chronic abdominal pain 148
Organophosphorus compounds 652
common 652
Organophosphorus poisoning 652
Ornidazole 814
Ornithine
cycle 591
transcarbamylase deficiency 591
translocase deficiency 591
Oro-facial chorea 196
Oronasal mask 678f
Orthopedics 468
Osteomalacia 83
Osteomyelitis 93, 97, 476, 478
chronic 476, 476f
Osteopenia 358, 358f
Osteopetrosis 369, 823f
Osteoporosis 358, 358f
Osteosarcoma 397
surgery for 398
treatment of 398
Otitis externa 408
acute 423
Otitis media
acute 406, 425
bacterial 119
recurrent 570
Otorhinolaryngology 405
Otoscopy 407
Ototoxicity 716
Ovalocytes 352
Ovarian cysts 538, 613
benign 337
Ovarian torsion 337f
Ovarian tumor 335
classification of 335
large right 337f
staging of 336
Oxcarbazepine 54, 56
Oxidative phosphorylation disorders 602
Oxybutynin 306, 727
Oxygen 245, 638, 669
cascade 669, 669f
hood 671, 671f
safety 673
saturation 636
monitoring of 682
supplementation, target spo2 17
therapy 669
Oxytocin nasal spray 68
P
Packed cell
transfusion 356, 362
volume transfusion 17
Packed red blood cell 77
Packed red cell transfusion 348
Paediatrician, role of 795, 796, 798
Pain
chronic abdominal 146, 147
severe 660
Palilalia 173
Pallister-Hall syndrome 528
Pallor 16, 28, 545
Palmar creases, single 571
Palmar erythema 156f
Palpable testis 317
Palpebral conjunctiva, upper 278f
Palpitations 613
Panayiotopoulos syndrome 55
Pancreas
divisum 166
ectopic 772
Pancreatic duct rupture 166
Pancreatitis 154
acute 163, 613, 645
recurrent 166
edematous 165f
Pancytopenia 368
Panic disorder 707, 729, 730
Pantothenic acid 87, 90, 91
PAPA syndrome 516
Papular lesions 507
Papular urticaria 429, 431, 447
Papules 443f
Paracetamol 100, 647, 648, 835
drops 650
overdose 650
poisoning 647
Paralysis 612, 653, 719
Paralytic squint 456
Paraphimosis 342, 344, 345, 345f
Parasite lactate dehydrogenase 108
Parasite's eggs 431
Parasitic meningitis 186
Parathyroid hormone 84, 86, 301
Parenchymal appearance 323
Parenchymal disease 664
Parenchymal thickness 307, 323
Parental height, mid 539
Parenting style 33
chart 34, 34f
two dimensions of 33
Paresthesia 545
Parkinson's disease, juvenile 200
Paromomycin 814
Parry-Romberg syndrome 509
Partial urea cycle defect 591
Parvovirus 368, 506
infection, chronic 375
Patent ductus arteriosus 14, 16, 227, 233
Patent foramen ovale 230
Pauci-immune glomerulonephritis 503
Peak alveolar volume 686
Peak expiratory flow rate 636, 684, 687
Peak flowmetry 255
Peak height velocity 45
Peak inspiratory
flow 684
pressure 684, 686, 687
Pearson syndrome 373
Pediatric intensive care unit 671, 820
admission 644
Pediatric practitioners 699
Pediatric rheumatology 494, 517t, 522, 524
biologics in 520
disease 523
disorders 522t
therapeutics in 517
Pediatric surgery 747
Pediatric vasculitides 499
Pediatric vasculitis
classification of 494
diagnosis of 494, 495t
etiopathogenesis of 494t
Pediculocide 432
Pediculosis capitis 430, 430f, 431f
Pellagra 89
Pelvic
fracture 330
inflammatory disease 613
kidney 574
ultrasound 28
Pelviureteric junction obstruction 289
severe 289
Pendred syndrome 715
Penicillin
G 5
prophylaxis 362
sensitivity 407
V 210
Penile cancer 344
Penile edema 321
Penile growth 45
Penile hematoma 321
Penile hypospadias, mid 319
Penile shaft, base of 320
Penile trauma 331
Penis 46
Penoscrotal hypospadias 320
Peptic ulcer disease 147
Peptide, calcitonin gene-related 316
Perampanel 54
Percutaneous drainage, role of 815
Perennial allergic conjunctivitis 278, 466
Periampullar duodenal stenosis 772
Pericardial effusion 608, 820, 830f
Pericarditis 219
constrictive 220
infectious 219
noninfectious 219
recurrent 220
Perichondritis 425
Perilesional eczema 434
Perinatal asphyxia 777
Perinatal stroke 22
Perineal hypospadias 320
Periodic fever 517
Periodic fever syndrome 515
cryopyrin-associated 493, 516
Peripheral nerve sheath tumor, malignant 576
Peripheral perfusion, poor 16
Peripheral smear 352, 364, 367
examination 387
study 283
Peritoneal bands 774
Peritonsillar abscess, treatment of 412
Periungual fibromas 581
Perlman syndrome 748
Peroxisomal disorders 603, 604
Peroxisomal sterol carrier protein-X deficiency 603
Peroxisome biogenesis, disorders of 603, 608
Persistent disease 490
Personal space solitude 629
Personality disorders 620
Perthes disease 479, 479f
Pertussis 58, 131
Pervasive developmental disorder 705
Pes planus 570
Petechiae 8
Petrolatum, hydrated 445
Peutz-Jeghers syndrome 332, 336
Pfeiffer syndrome 585, 586
PHACE syndrome 462
Pharmacotherapy 52, 715
Pharyngitis 100, 517
acute 408
Phenacetin 364
Phenobarbitone 54
Phenotypes 572
Phenoxymethylpenicillin 210
Phenylbutazone 368
Phenylepherine 21
Phenylketonuria 18, 708
Phenytoin 54, 56, 351
Pheochromocytoma 576, 731
Philadelphia type craniosynostosis 586
Philtrum, long 41
Phimosis 342, 344f
pathological 343, 343f, 345
Phobias, specific 729, 730
Phonological disorder 719
Phosphide 656
poisoning 656
Phosphoenol pyruvate carboxy kinase deficiency 544
Phosphofructokinase, deficiency of 611
Phosphorus 8, 86, 301, 644, 656
Phosphorylase
B kinase 611
kinase deficiency 610
Photon emission computed tomography, single 50
Photophobia 88
Phototherapy 8, 88
Physical abuse 788
Physician global disease 487
Physiologic phimosis 342f, 343, 343f, 344
Physiotherapy 569
Phytanic acid 604
Phytanoyl CoA hydroxylase deficiency 603
Pierre-Robin sequence 253
Pigeon chest 84
Pimozide 200
Pinna, large 41
Piperacillin 5
Piperonyl butoxide 431
Pituitary adenoma 528
Pituitary apoplexy 528
Pituitary hormone deficiency, multiple 528
Pituitary resistance syndrome 535
Pityriasis alba 449
patch of 449f
Pityriasis rosea 273
Plaque brachytherapy 463
Plasma
amino acids 42
ascorbic acid 93
cells 406
membrane functions, disorders of 596
protein-A, pregnancy associated 569
total homocysteine 42
Plasmalogens 604
Plasmodium
falciparum, symptoms of 838
vivax symptoms of 838
Plastic bronchitis 243
Plateau pressure 684, 687
Platelet
count 379, 382f, 520, 524
dysfunction 379
morphology 369
transfusion 3, 112, 370
Plethora 16
Pleural cavity 813
Pleural disease 664
Pleural effusion 608, 768, 815
Pleural fluid 252, 827f
Plexiform neurofibroma 575, 576
Plica polonica 430
Plus disease 465
Pneumatocele 768
Pneumatosis intestinalis 779, 779f
Pneumococcal conjugate vaccine 131, 294
Pneumococcal polyvalent vaccine 128
Pneumococcal vaccination 128
Pneumococcus 422, 460, 835
Pneumomediastinum 824f
Pneumonia 95, 104, 115, 119, 435, 678, 824, 825
bacterial 250
bilateral 826
classification of childhood 104t
community acquired 103
congenital 13, 768
diagnosis of 104
risk of 760
severe 104
therapy for 105t
Pneumonitis 815
interstitial 212
Pneumoperitoneum 779, 821
Pneumothorax 768, 820
Poikilocytosis 352
Poisoning 633
Polio 58, 131
vaccine, inactivated 131
Poliomyelitis 176, 177
Poliovirus 128
vaccine 129
Polyangiitis 502
microscopic 502
Polyarteritis nodosa 97, 493495, 499
childhood 500b
Polyarthralgia 209
Polyarthritis 512
Polycystic kidney disease 289
autosomal
dominant 289
recessive 289
Polycystic ovary syndrome 66, 557
Polycythemia 6, 16, 777
Polydactyly 557
Polyembryoma 335
Polymerase chain reaction 96, 252, 602
real-time 244
Polymyositis 179
Polysaccharides, capsular 128
Polytherapy 56
problems of 56
Pompe's disease 609, 610
Porphyria 612, 613
acute intermittent 612
congenital erythropoietic 612
cutanea tarda 612
cutaneous 613
hepatoerythropoietic 612
treatment of 614
Porphyrins 612
Portal vein gas 779, 779f
Positive airway pressure, bubble continuous 679f
Positive end-expiratory pressure 684
Postexposure prophylaxis 128
Postextubation stabilization 678
Postneurosurgery 79
Postpoliomyelitis paralysis 473
Postpubertal males 332
Post-transplant immunosuppression 394
Post-traumatic
physeal arrest 474
stress disorder 730
Prader's orchidometer 539
Prader-Willi syndrome 40, 41, 78, 317, 528, 556, 558, 608, 708
Pradhan Mantri Surakshit Matritva Abhiyan 58
Pralidoxime 654
Preauricular cyst 425
Preauricular lymphadenopathy 458
Precocious puberty 538, 540f, 541fc, 542fc, 576
familial male limited 542
peripheral 543
Predilection, sites of 430
Prednisolone 383
Prednisone 393
Pregnancy 86, 368
management 580
vaccines to administered in 127
Prehn's sign 341
Premature infants 464
Premature menarche 538
Premature pubarche 538
Premature thelarche 538
Prematurity 17t
anemia of 385
apnea of 16
Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act 789, 795
Preseptal cellulitis 459
Pressure controlled ventilation 688f
Pressure volume loop 686
components of 691
Pressurized metered-dose inhalers and device 258
Priapism 361, 362, 362f
Primaquine 364, 838
Primipara 66
Pristanic acid 604
Probiotics 270
Procalcitonin 283
Procarbazine 393
Prognostication, scoring system for 158
Prohibition of Child Marriage Act 789, 794
Prolactinoma 554
Promotive health 58
Prophylactic antibiotics 314
Prophylactic dose 29
Prophylaxis, pre-exposure 128
Propionic acidemia 593, 595
Propylthiouracil 535
Prostaglandin 229
Prostatic utricle, enlarged 320
Protection of Children from Sexual Offences Act 789, 791, 794
Protein 31
cerebrospinal 50
deficiency, trifunctional 596
energy malnutrition 74
O-glycosylation, disorders of 607
Proteinuria 294
heavy 294
Prothrombin time 656
Proton pump inhibitor 293, 518
Protoporphyria
erythropoietic 612
X-linked 612
Proximal penile
hypospadias 320
region 320
Prune-Belly syndrome 317
Pruritus 269
Pseudocyst 164
Pseudohypertrophy, bilateral calf muscle 531f
Pseudohyponatremia 674
Pseudohypoparathyroidism 556
Pseudomembrane 458
Pseudomonas aeruginosa 251, 423
Pseudo-obstruction 784
Pseudoprecocity 535
Pseudotumor cerebri 557
Psoriatic arthritis 484, 485, 488, 512
Psychiatric illness 580
Psychiatric syndrome 192
Psychoeducational tests 743
Psychogenic seizures 172
Psychological abuse 789
Psychophysiologic insomnia 725
Psychosis 591, 742
Ptosis 374, 600, 601
Pubarche 45
Pubertal age 543
Pubertal delay 535
Pubertal disorders 535
Pubertal gynecomastia 553
Pubertal induction
in boys 551t
in girls 552t
Pubertal testis 340
Puberty
age of onset of 44
central precocious 538, 540f, 543
duration of 44
hormonal changes in 45
major physical changes of 44
sequential changes of 45
Pubic hair 45, 46
development 45
staging 539
Pulmonary artery 758
Pulmonary blastema 768
Pulmonary blood flow 229, 230, 232
duct-dependent 228
Pulmonary edema 296, 633, 645, 678, 824
Pulmonary function tests 250, 254, 687
Pulmonary hemorrhage 387
Pulmonary hypertension 232, 362, 760
management of 758
Pulmonary lymphangioleiomyomatosis 581
Pulmonary plethora, loss of 830f
Pulmonary sequestration 768, 769
Pulmonary stenosis 229, 230, 232
severe 230
Pulmonary tuberculosis 112, 113, 513
Pulmonary venous hypertension 232
Pulse
oximeter screen 20
volume 4
Pure-tone audiometry 574
Purine 42
synthesis antagonists 351
Purulent discharge 438f
Pustules 443f
Pyelonephritis, acute 613
Pyeloplasty 325
Pyloric muscle 772
Pyloric stenosis 776
hypertrophic 770
Pyloric tumor 773f
Pyloromyotomy 773f
Pylorospasm 772
Pyoderma gangrenosum 516
Pyogenic arthritis 516
Pyogenic infection, secondary 428
Pyomyositis 476
Pyrazinamide 113, 114
Pyrethroids 431
Pyrexia of unknown origin 97
causes of 97t
Pyridoxine 87, 89, 91, 602
Pyriform fossa 755f
Pyrimidine antagonists 351
Pyrimidines 42
Pyruvate carboxylase deficiency 544
Q
Quad screen 569
Quadrivalent vaccines 140
Quick SOFA score 697, 697t
Quinidine 364
R
Rabies 128, 189
vaccine 129
Raccoon eyes 750
Rachitic rosary 84, 84f
Radial artery, absent 374
Radioimmunoassay 84
Radionuclide scan 310
Radiotherapy, intensity modulated 397
Radius syndrome, absent 373
Ragged red fibers 601
Ramstedt for pyloromyotomy 773
Rash 16, 99, 99t, 100
distribution of 100
progression of 100
Rashtriya Bal Swasthya Karyakram 59
Rashtriya Kishor Swasthya Karyakram 59
Rat killer poisoning 654
Rathke's cleft cyst 528
Raynaud phenomenon 510, 511
Reaction, type I 261
Recombinant erythropoietin treatment 388
Recombinant growth hormone therapy 575
Recombinant human prolactin 68
Rectal bleeding 152
Rectal polyp, hamartomatous 581
Rectal route disimpaction 151
Red blood cell 89, 295, 365
count, low 348
Red cell
aplasia 154, 368
distribution width 348, 355
membrane disorders 365
precursors 375f
transfusion 366
Red eye
causes of 458
in child (infections) 458
Red reflex test 452
Reddish-pink round 463
Refraction 718
Refractive error 50, 453, 457, 461
Refractory enuresis 306
Refsum disease 603
infantile 603
Rehabilitation 138
Relactation 68
Remitting disease 490
Renal angiomyolipoma 581, 582
Renal anomalies 371, 574, 765
Renal artery
disorders 215
stenosis 576
Renal biopsy, indications for 293
Renal cell carcinomas 580
Renal cysts 580
multiple 581
Renal disease 503
Renal failure 296, 360, 667
Renal function
differential 324
monitoring 311
test 244, 245, 283, 308, 310, 520, 656
creatinine 308
urea 308
Renal image-central renal complex 307
Renal impairment 108
Renal injury 326
classification of 327, 327f
Renal insufficiency, chronic 37
Renal manifestations 500
Renal parenchymal
changes 308
disease 215
Renal pelvis
and calyces, dilated 323f
diameter 323
Renal rickets 202f
Renal tubular acidosis 298
Renal ultrasound 323f
postnatal 323
Renal vein thrombosis 215
Renoparenchymal disease 216
Renovascular disease 215, 216
Renovascular injuries 328
Repair, types of 321
Repetitive behaviors 52
Replacement therapy 537
Replogle tube 763
Respiratory acidosis 665, 667, 668
Respiratory alkalosis 665, 667, 668
Respiratory diseases 238
Respiratory distress 419, 825f
onset of 11
syndrome 11, 13, 464, 466
acute 105, 164, 191, 825
Respiratory failure 639, 653
Respiratory infection
recurrent 764
upper 95, 641
Respiratory rate 4, 682f
Respiratory support 17
Respiratory syncytial virus 410
Respiratory system 664
Respiratory tract 274
Restless leg syndrome 196
Resuscitation, cardiopulmonary 642
Reticular dysgenesis 368
Reticulocyte 364
count 354f
hemoglobin content 348
start 387
Reticulocytopenia 386
Reticulocytosis, compensatory 386
Retina, astrocytic hamartoma of 463
Retinal achromatic patch 581
Retinal capillary hemangioma 463
Retinal dystrophies 718
Retinal nodular hamartomas, multiple 581
Retinal vascularization, normal 464
Retinitis pigmentosa 600, 601
Retinoblastoma 452, 462, 463
Retinoic acid 443
Retinopathy of prematurity 464, 718
classification of 464
risk for 464
screen 21
Retractile testis 316
Rett's disorder 40
Rett's syndrome 201, 708
Reye syndrome 192
Rh factor 29
Rhabdomyoma 581
cardiac 581
Rhabdomyosarcoma 332, 333, 400, 462, 463, 576, 768
Rheumatic fever 209
revised diagnostic criteria for 209t
Rheumatoid factor 484
Rheumatologic disorders 476
tests specific to 525
Rheumatology 482
Rhinitis, symptoms of 416
Rhinorrhea 412
Rhizomelic chondrodysplasia punctata 603
Rhizomelic shortening 578
Rhonchus 238, 240
Rib 823f
Ribcage defects 765
Riboflavin 87, 88, 91, 602
deficiency 88f
Rickets 83, 86f
features of 83
Rickettsia 114, 217
encephalitis 116
Rickettsial disease 114
Rickettsial infections 95, 97, 99, 101, 109, 114, 496
Rifampicin 113, 114, 116
Right bundle branch block 234
Right device 670
Right to Education 787
Act 746, 789, 794
Rigidity 200
Ringer lactate 359
Risperidone 52, 67, 200
Risus sardonicus 656
Rituximab 384
Rlectrolyte imbalance 6
Road traffic accident 330
Robin sequence 41
Rodenticide 654
poisoning 654
clinical syndromes in 656t
Rosenberg's scale 624
Rotavirus 136, 142
gastroenteritis, severe 137
vaccine 137
impact of 137
lower efficacy of 137
vaccine impact 136
controversies 136
solutions 136
Rothmund-Thomson syndrome 373
Rotor syndrome 7
Round facies 41
Routine neonatal vaccines 130
Rubella 206, 217, 454, 455, 710
syndrome, congenital 47, 413
Rufinamide 54
Rumack-Matthew nomogram 648, 648f
S
Sacral agenesis 337
Saethre-Chotzen syndrome 584
Safety concerns 127
Salbutamol 682
Salicylate poisoning 667
Saline
normal 673
solution 359
Saliva, drooling of 436f
Salivation 653
Salmonella 142
enterica 105, 134
typhi 153
Salt wasting 559
congenital adrenal hyperplasia 559
Sandifer syndrome 144
Sarcoptes scabiei 428
Scabies 428, 428f, 448
lesions of 429f
Scaphoid abdomen 757
Scapula 823f
Scardino-Prince vertical flap pyeloureteroplasty 325
Schiller-Duval bodies 332
Schizophrenia 27, 48, 742
Schwartz formula, modified 296
Scintigraphy 754
Sclerodactyly 510
Scleroderma, juvenile 508
localized 508, 509fc
Sclerosing panencephalitis, subacute 193, 195
Sclerosis, juvenile systemic 508, 509, 510f
Scoliosis 480, 571, 576, 831f
requiring surgery 576
Scorpion sting 678, 825f
Scrotal exploration 341
Scrotal halves 320
Scrotal hypospadias 320
Scrotum, erythematous 341
Scrub typhus 115
Scurvy 379
Scutula 438
Seasonal illness 243
Sebaceous glands 334f
Seborrhea 442f, 443f
Seborrheic dermatitis 446
Secnidazole 814
Seizure 16, 55, 56, 189, 568, 571, 575, 580, 594, 608, 613, 653, 656, 822f
complex febrile 54
disorders, pre-existing 27
focal 55
generalized 55
neonatal 22
uncontrolled 635
Self-awareness 47
Self-gratification behavior 172
Sensory stimulation 77
Sepsis 9, 16, 18, 592, 594, 597, 599, 604, 696
early onset 3
late onset 3
management of 5t
neonatal 3
risk factors for 3t
screen 6, 6t
severe 4
Septic arthritis 363, 491
Septic shock 15, 667, 696, 699, 699t
management of 698fc
pathophysiology of 697fc
recognition of 696, 697
Septicemia 13
Septo-optic dysplasia 528
Sequential organ failure assessment score 697
Sequestration crisis 361, 362
Serology 813
Serositis 504
Serotonin reuptake inhibitors, selective 708, 730
Serous tumors 335
Serpiginous 447f
Sertoli cell 332
tumor 332
Sertoli stromal cell tumors 335
Sertoli-Leydig cell tumors 336
Serum
albumin, low 155, 291
antibodies 813
bile acids 158
bilirubin 155
calcium 79, 642
carbohydrate deficient transferrin 608
complement levels 526
cortisol 79, 546
creatine kinase 567
creatinine 297
electrolytes 245, 301, 634, 644
globulin 158
glutamic oxaloacetic transaminase 9, 154, 650
glutamic pyruvate
transaminase 9, 154
transferase 650
growth hormone 546
immunoglobulin A, total 806
iron 387
pH 546
potassium 676
soluble transferrin receptors 348
Sex cord 335
Sex steroid
administration, exogenous 538
priming 530
Sexual abuse 331, 788, 789
Sexual assault forensic evidence kit 792b
Sexual development 529
Sexual differentiation, disorders of 316, 320
Sexual maturity rate 36, 45, 539
assessment 539t
Sexual violence 791fc
Sexually transmitted
diseases 790, 793
infection 791
Shagreen patch 580, 581
Shaken baby syndrome 788
Sharpened wooden spatula 434
Sheehan's syndrome 66
Shigella 142, 837
Shiny abdominal wall 778f
Shock 13, 14, 108, 388, 647, 776, 777
cardiogenic 13, 15, 664
clinical pointers for 14t
cold 697
distributive 13, 664
drugs in 15t
endocrine 13, 15
hypovolemic 13, 15, 386, 664
low energy 222
management of 5, 780
neonatal 13
neurogenic 13, 15
refractory 656
Short bowel syndrome 147, 777
Short neck 374
Short stature 40, 574
differential diagnosis of 37, 37t
disproportionate 578
evaluation of 38, 39fc
familial 37
idiopathic 37
Shuddering attacks 172
Shunt
infections 185
left to right 233, 235
lesions, left to right 234
Shwachman-Diamond syndrome 368, 373
Sick baby 2
Sick child 369, 662
in outpatient department 662
Sick septic patient 813
Sickle cell
anemia 18, 185, 360, 365
disease 360
hemoglobin 360
Sickling test 363f
Sideroblastic anemias 360
Simian crease 41
Simple replacement transfusion 387
Simple virilizing 559, 560
congenital adrenal hyperplasia 561
Simpson-Golabi-Behmel syndrome 203, 750
Sinus 752, 754, 755
branchial 754
of Valsalva, ruptured 233
Sinusitis 97, 119
Sistrunk operation 753
Skeletal abnormalities 604
Skeletal anomalies 371
Skeletal deformities 374
Skeletal dysplasias 606
Skeletal films 710
Skin 119, 285
barrier defects, heritable 268
dry 535
fold freckling 576
lesions 444
manifestations, variable 500
prick test 279
ulcers 508
Skull bones, enlargement of 202
Sleep
anxiety 725
cycles 620
debt 621
deprivation syndrome 621
disorder 357, 724
limit setting 725
disturbed 304
hygiene 725
principles of 725t
onset association disorder 725
Sluggishness 531
Small bowel
biopsies 807
histology, interpretation of 808
obstruction 760
Small vessels, vasculitis of 285
Smith-Lemli-Opitz syndrome 782
Sniffing glue 368
Snoring 238
Snuffles 238
Soave procedure 783
Social anxiety disorder 729, 730
Social communication disorder 705
Social phobias 729, 730
Social worker, role of 796
Society for Fetal Urology 323
Infant Hydronephrosis Grading System 307t
Sodium
bicarbonate 602
monofluoroacetate 656
valproate 54, 56
Soft tissue infections 119
Solitary rectal ulcer syndrome 152, 153
Somatostatin 770
Sotos syndrome 203, 748
Spasmodic croup 639, 641
Spasms, infantile 55, 580
Spastic diplegia 182
Spastic hemiplegia 182
Spastic quadriplegia 182
Specific organ involvement, intervention of 664t
Speech
and language deviancies 742
apraxia of 719
disorders 719
slurred 608
therapy 569
Spermatocele 335
Sphenoid dysplasia 575
Sphenoid wing dysplasia 576
Spherocytosis 365
hereditary 365, 366, 366f
Sphincter inactivity 339
Sphingolipidoses 605, 608
Spina bifida 337, 338, 472, 473f, 572
cystica 572
occulta 572
Spinal cord 750
compression 751
injury 338
neural tumors 473
signs 191
trauma 473
tumors of 338
Spinal dysraphism 337, 572
closed 572
Spinal muscular atrophy 587, 611
phenotypes, spectrum of 588t
Spinal stenosis 579
Spine anomalies, congenital 586
Spine
MRI of 338
progressive curvature of 608
Spirometry, indications for 255
Splenectomy 357f, 366
Splenic sequestration 362
Spontaneous bacterial peritonitis 158
Spontaneous breath 686f
Spotted fever 115
Sprengel deformity 374
Sputum 242
Squamous cell tumors 335
Squint 456
direction of 456
family history of 457
latency of 456
Staining teeth 349f
Stapedial foot plate 185
Staphylococcus 217
aureus 3, 103, 139, 251, 282, 409411, 422, 423, 432, 460, 476, 641, 835, 837
saprophyticus 282
Status asthmaticus 636
Status dystonicus 198
Status epilepticus 633
early 633
febrile 633
late 633
protocol 635
refractory 635
Stem cell transplant 359, 371, 375
Stem cell transplantation
allogenic 371
hematopoietic 373, 606
Stenosis 817
Steroid 5, 15, 79, 114, 219
inhaled 265
therapy 211, 375
topical 270
Stertor 238
Stiff-Baby syndrome 171
Stiripentol 54
Stomach bubble 830f
Stomatitis, aphthous 517
Stool tests 275
Stop hypertension 216
Strabismus 374, 453, 456, 457, 462, 570, 608
Strawberry nevi 462
Streptobacillus moniliformis 496
Streptococcal antibody tests 526
Streptococcal pharyngitis, primary prevention for 210t
Streptococcus 185, 217, 409, 460
agalactiae 186
pneumoniae 139, 184, 187, 251, 362, 406, 409, 835
pyogenes 139, 251, 410, 837
spp 460
Stress 622
Stridor 238, 239, 643, 693695
at rest 643
biphasic 238, 643
congenital 426
differential diagnosis of 696, 696t
etiology of 693, 693b
expiratory 238
inspiratory 238
management of 694
persistent 693
recurrent 693
stepwise approach to 693
Stroke 139, 636
Stromal cell tumors 332
Stromal tumors 335
Strongyloides stercoralis 446
Structural anomalies 306
Strychnine 656
Sturge-Weber syndrome 41, 203
Subcorneal pustule 433
Subcutaneous immunotherapy 277
Subcutaneous nodules 209
Subdural effusions 188
Subependymal nodules 580, 581
Subglottic stenosis 426, 693
Sublingual immunotherapy 277
Substrate reduction therapy 606
Subtle markers 4
Sudden infant death syndrome 144
Sugar intake 31
Suicidal behavior 734
Suicidal ideation, risk assessment of 734
Sulfa 368
Sulfadiazine 364
Sulfadimidine 364
Sulfamethoxazole 357
Sulfanilamide 364
Sulfapyridine 364
Sulfasalazine 486
Sulfonamide 364
Sulfones 364
Sulfur cups 438
Sump catheter 763
Supplemental lactation technique 68, 68f
Supportive care 4, 8, 14
Supportive therapy 362, 370
Suppurative thyroiditis 535
Suprapontine 337
Suprapubic aspiration 283
Supratentorial tumors 396
Supratherapeutic overdose, repeated 649
Supraventricular tachycardia, paroxysmal 222
Surgery 325, 379, 457
indications for 308
Surgical management 317, 759
Survival motor neuron 587
Sweat chloride 250
Swelling, pale 278f
Swenson procedure 783
Swimmer's ear 424
Swollen testis 341
Sympathetic nervous system, activation of 545
Symptomatic children 808fc
Symptomatic seizures 22
Synchronized cardioversion 222, 223
Syncope 172
Syndrome of inappropriate antidiuretic hormone secretion 191
Syndromic clubfoot 472
Syndromic craniosynostosis 584, 584t
Syndromic obesity 78
Synovial fluid examination 484
Synovitis hip, transient 480
Synthetic pyrethroid 431
Syphilis 454
congenital 9
secondary 155
testing for 28
Systematic desensitization 730
Systemic arthritis 484
Systemic blood flow, duct-dependent 228
Systemic disease 553
Systemic juvenile idiopathic arthritis 485, 488, 518, 520, 524
Systemic lupus
erythematosus 27, 97, 227, 273, 286, 298, 390, 493, 503, 518, 520
differential diagnosis of 505
management of 505t
international collaborating clinics 504t
Systemic reactions 277
Systemic sclerosis 511
Systemic steroids 638
Systemic symptoms, severe 778
Systolic blood pressure 214
Systolic hypertension 215
T
Tachycardia 16, 165, 220, 545, 633
digitalis induce 222
Tachypnea 12, 16, 386, 827f
of newborn, transient 13
Tacrolimus 467
Takayasu arteritis 495, 501
childhood 501t
classification of 502t
Talking to parents, strategies for 126
Tandem mass spectroscopy 51
Tanner's method 541
Tanner's staging 45, 46, 553, 557
Tarui's disease 610
Tay-Sachs disease 203, 708
Tazobactum 5
Tdap/Td vaccine 30
Technetium-99m
bone scan 751
mercaptoacetyltriglycine 308
Telangiectasia 349
Temperamental traits 714
Temperature monitoring and control, promote 124
Temporary causes 715
Tendo-Achilles tightness 470
Tenofovir disoproxil fumarate 811
Tense anterior fontanel 16
Tense hydrocele 335
Tension-type headache 174
types of 174
Teratoma 332
immature 335
mature 335
Terbutaline, intravenous 639
Testes 316
appendages of 342f
ascending 317
bilateral undescended 316
ectopic 317
gangrenous 340f
iatrogenic undescended 317
intra-abdominal 318
tumors of 331
Testicular adrenal rest tumors 560
Testicular descent, stages of 316
Testicular growth 45
early 45
Testicular torsion 340
Testicular tumors 331, 553
pediatric 335
staging of malignant 333
Testicular volume 539
Tetanus 58
diphtheria, and pertussis 127
Tetramethrin 431
Thalassemia 353
diagnostic workup for 355
intermedia 353, 354f
major 353, 354f
minor 353
prenatal diagnosis of 360
syndromes 353
Thallium 656
Thelarche 45
Therapeutic food, ready-to-use 77
Therapeutic modalities 508
Thermal injury 366, 639
Thermal instability 18
Thiabendazole 446
Thiamine 87, 91, 602
Thiamine-responsive megaloblastic anemia 88
syndrome 351
Thiopentone 635
Third branchial cleft 755
Thoracolumbar kyphosis 579
Thoracoscopic drainage, video-assisted 252
Thoracoscopic surgery, video-assisted 253
Thoracoscopy 766
video-assisted 105
Thoracotomy 766
Thornwaldt's cyst 410
Threonine 601
Thrombocytopenia 8, 154, 155, 369, 373, 504, 780
amegakaryocytic 368
neonatal 2
Thrombotic episode 294
Thrombotic microangiopathy 504
Thumbs
abnormalities 374
double joined 570
Thymoglobin 370
Thymus hypoplasia 418
Thyroglossal cyst 752, 753
Thyroglossal duct 753
Thyroid 182
disease, autoimmune 534
disorders 731
dysgenesis 530
dyshormonogenesis 535
function 28
assessment 574
studies 49
test 29, 51, 79, 529, 550, 753
hormone beta-receptor mutation 535
hormone resistance 537
syndromes 535
profile 8, 742
scan 753, 754
stimulating hormone 27, 29, 359, 531, 533, 555, 574, 753
tissue 754
Thyroiditis 509
infectious 535
subacute 535
Thyrotropin releasing hormone 68
Thyroxine replacement 558
Tiagabine 55, 56
Tibia, pseudarthrosis of 576
Tic 200
disorders 744
treatment of 200
Tick borne virus 801
Tick-to-human transmission, risk of 802
Tinea capitis 437, 441
noninflammatory type of 438f
Tinidazole 814
Tinnitus 577
Tiredness 610
Tissue
biopsy 611
diagnosis 399
fibrous 768
transglutaminase 806
Titrate and monitor 672
T-lymphocyte defects 185
Toilet training 151
forced 728
regular 150
Tongue, protruding 532
Tonsillar membrane 640f
Tonsillectomy 411
Tonsillitis 408, 410, 412
bacterial 410
Tonsils, inflammation of 410
Topicamide 21
Topiramate 55, 56
TORCH infections 710
Torsion 317
Torticollis
benign paroxysmal 172
with opisthotonus 144
Total leucocyte count 6, 382, 520
Tourette's syndrome 173, 744
Toxic shock syndrome 13
Toxicity
low 655
mechanism of 647, 657
severity of 655
Toxin 177
Toxoplasma 455
Toxoplasmosis 9, 97, 206, 454, 710
Trabeculae, loss of 92
Trabeculotomy 461
Tracheitis, bacterial 639, 641
Tracheobronchial disease 693
Tracheoesophageal fistula 6, 659, 760, 762f, 817
Tracheomalacia 693
Tracheostomy
sites 670
tube 678f
Trampoline, use of 579
Transabdominal phase 316
Transairway pressure 686
Transaminitis 804
Transcobalamin deficiency, anemia of 388
Transcutaneous bilirubinometer 20, 20f
Transfusion therapy, complications of 356
Transfusion, platelet threshold for 2t
Transgender 732
Transinguinal orchidopexy 318f
Transinguinal phase 316
Transition objects 725
Translucency-subcutaneous emphysema, vertical 824f
Trauma 166, 335, 342, 528
extragenital 793
informed care 789
nonaccidental 477
Traumatic brain injury 633, 699, 702b
clinical spectrum of 700
types of, serious 700t
Traumatic neuropathy 176, 179
Traumatic paralysis 473
Treacher-Collins syndrome 253, 413, 420
Tremor 200, 545, 653
familial essential 196
Triad stridor 694
Triangular facies 41
Trichophyton 437
Trichophyton
schoenleinii 439
tonsurans 438, 439
violaceum 438, 439
Trigeminal autonomic cephalalgia 175
Triglycerides, medium-chain 8, 598
Trihexyphenidyl 198
Trimethoprim 357, 284
Triphalangeal thumb 374
Tripod sign 177
Triptorelin 542, 543
Tris buffer 602
Trismus 656
Trisomy 41
Trivalent vaccines 140
Trivandrum development screening chart 44
Tropical fevers 95
Tropical splenomegaly syndrome 606
Trouble-some symptoms 143
Tube test 98
Tubercle bacilli 153
Tubercular arthritis 491
Tuberculosis 28, 58, 97, 112, 129
drug doses for 114t
pediatric 112
Tuberous sclerosis 41, 55, 709, 710
complex 580
Tubular disorders, secondary to 298
Tubularized incised plate urethroplasty 321
Tubulointerstitial nephritis 512
Tumor 528, 538, 553
adrenocortical 79
clear cell 335
embryonal 748
endobronchial 693
endometrioid 335
histology of 749
hypothalamic 396
infratentorial 396
intracranial 556
intraocular 462
markers 334
necrosis factor receptor-associated periodic syndrome 515
size, large 398
unclassified 335
undifferentiated 335
Tunica vaginalis 340
high investment of 340
Turner syndrome 40, 41, 390, 549, 573
Twin-twin transfusion 387
Typhoid 95, 128
conjugate vaccine 133
cost-effectiveness of 134
fever 134
vaccine 129
Tyrosinemia 9, 18
U
Ulcers, unhealed 359f
Ultrasonography, cranial 49
Ultrasound, abdominal 611
Umbilical artery 778
Umbilical cord blood 373
Umbilical hernia 532
Umbilicated papules 434
Uncinaria stenocephala 446
Undescended testes 316, 317, 320, 331, 554
true 316
United Nations Convention on Rights of Child 786
United States Preventive Services Task Force 452
Universal Immunization Program 58, 138
Universal Salt Iodinization 537
Upper airway
acute 639
burns 642
chemical 642
thermal 642
disease 664
obstruction 305, 678
acute 639, 640
causes of acute 639t
patent 420
Urban Community Health Centres 60
Urban Primary Health Centres 60
Urea acid cycle defects 602
Urea cycle 591
defect 591
complete 591
types of 591
disorders 594, 597, 599, 604, 608
Ureter 323
ectopic 307
injuries 328
Ureteric dilation 308
Ureterocele 307
Ureteropelvic junction obstruction 307, 322, 574
Ureterostomy 311
Ureterovesical junction obstruction 307
Urethral atresia 307
Urethral catheterization 283
Urethral diverticula 321
Urethral injury 329
grades of 330
Urethral meatus 320
abnormal location of 319
Urethral stricture 321
Urethral valve
posterior 306, 307, 309, 310f
postnatal management of 311
Urethrocutaneous fistula 321
Urethrogram, retrograde 330
Urethrography, retrograde 326
Urethroplasty 322f
Uric acid 301
metabolism, disorders of 611
Urinary catecholamine metabolites 751
Urinary diversion 339
Urinary frequency 652
Urinary incontinence 338
Urinary sphincter, incompetent 339
Urinary stones 298, 302
Urinary tract
anomalies, upper 320
dilation
classification 323
postnatal classification for 323t
infection 95, 97, 119, 282, 288, 305, 323, 338
diagnosis of 283
history of 312
management of recurrent 283
recurrent 282, 283, 344
role of recurrent 283
Urination problems 613
Urine 301
albumin 29
analysis 526
collection, method of 283
culture 8, 283
dipstick 283
ketones 546, 644
microscopy 283
organic acid 42
protein 297
red 612
Urodynamic study 310, 338
Urogenital defects 374
Urolithiasis 298, 299
Urology 315
Uropathy, obstructive 215
Ursodeoxycholic acid 8, 163
Urticaria 271, 274
acute 271, 272, 273
cholinergic 274
chronic 271273
giant 272f
lesions 428
vasculitis 273
US Food and Drug Administration 810
Usher syndrome 413, 715
Uveitic cataract 454, 455
Uveitis 512, 521
acute anterior 512
anterior 513
chronic 512
granulomatous 512
complications of 514
intermediate 513
pediatric 512
posterior 513
prognosis 514
risk of 512t
V
Vaccination status 100
Vaccination, two-dose 136
Vaccine
and cold chain managers 125
cold chain 124
hesitancy 125, 127
models and determinants 125
pregnancy recommendation 129
preventable diseases 27
Valve fulguration, primary 311
Vancomycin 5
Varicella 129, 217, 368
zoster virus 189, 454
Varicocele 335
Variegate porphyria 612
Vascular manifestations 511
Vascular ring 639
around trachea 243
Vasculitides 490
classification of childhood 496f
Vasculitis
antibody-associated 495
chronic 212
subacute 212
Vasoactive intestinal peptide syndrome 750
Vaso-occlusive crisis 361
Vasovagal syncope 172
Vena cava, left superior 229
Venereal disease research laboratory test 513
Venlafaxine 52
Venous blood gas 301
Ventilated child 828f
Ventilation 758
synchronized intermittent-mandatory 688
types of 677b
Ventilators, conventional 679
Ventilatory graphics, ABCD of 682
Ventilatory tubing 692f
Ventricular enlargement 202
Ventricular septal defect 229, 230, 233
Ventricular tachycardia 222
Ventriculoperitoneal shunt 579
Venturi mask 671
with valves 672f
Vernal keratoconjunctivitis 278f, 466, 467
Vertigo, benign paroxysmal 172
Vesicostomy 311
Vesicoureteral reflux, low-grade 320
Vesicoureteric reflux 282, 284f, 306, 307, 309, 310
Vessel vasculitis, large 494
Vestibular schwannoma 578
Vigabatrin 55, 56
Vinblastine 393
Vincristine 384, 393, 749
Vineland social maturity scale 44
Viral conjunctivitis 458
Viral croup 642
Viral encephalitis 189, 191t, 192t, 193, 194
differentiating features of 192t
Viral hepatitis 368
Viral infection 6, 178, 385, 833
congenital 592, 594, 597, 599, 604
Viral respiratory pathogen testing 244
Viral ribonucleic acid, detection of 804
Viral tonsillitis 411
causes of 410
Virtual bronchoscopy 243
Viruses causing hemorrhage 190
Visceral hemorrhage 387
Vision 457
defective 453, 822f
double 457
evaluation 51
impairment 50
Visual acuity 457, 718
assessment 453, 454
normal 458
Visual cortex suppresses 453
Visual development, critical period of 453
Visual discrimination 741
Visual field defects 50
Visual impairment 462, 717, 718
classification of 717t
etiology of 718t
Visual processing disorder 741
Visual rehabilitation 455
Vitamin
A 8, 31, 80, 80t
deficiency 80
prophylaxis program 81
B complex 87
deficiency 87
role of 87t
sources of 87t
therapeutic dose of 91t
B1 87
B2 88
B3 89
B5 90
B6 89
C 602
supplementation 93
C deficiency 91
radiological features of 93f
D 83, 83t
assay techniques 84
daily dose 85
dependent rickets 86
status 83
supplementation 271, 293
D deficiency 29, 83
high prevalence of 83
D3 8, 79, 83, 85
E 8, 602
K 8, 364
therapy 657
Vitrectomy, anterior 455
Vocal cord
palsy 423
bilateral 243
paralysis 639
Vogt-Koyanagi-Harada syndrome 513
Voice 528
change 241
disorders 720
Voiding and fluid intake diary 304
Voiding cystourethrogram 308, 310
Volume control
mode-continuous mandatory ventilation 684f
ventilation 687f, 688f
Volvulus 776
acute midgut 775
chronic 775
recurrent 777
Vomiting 212, 357, 545, 612, 822f
cyclic 174
differential diagnosis of projectile 772, 772t
failure to thrive 594
psychosocial 775
von Gierke's disease 609
von Hippel-Lindau syndrome 463
von Recklinghausen's disease 575
von Willebrand's disease 379
W
Waardenburg syndrome 572, 715
Waardenburg-Shah syndrome 782
WAGR syndrome 748
Waldeyer's ring protecting 408
Waterlow's classification 74, 75
Waterston classification 761, 761t
Wechsler intelligence scale 44
Weight gain 535
Weight loss 8
Wellcome trust classification 75
Werdnig Hoffman disease 611
Werner syndrome 544
Wernicke-Korsakoff syndrome 88
West Nile
encephalitis 192
virus 189
Westley croup score 641, 695t
Westley score 640, 641t
Wheeze 238240
acute 636
infantile 246
White blood cell 180, 252
count 524
White cell count 110, 115, 194
White reflex 453
White-coat hypertension 214
Whitehouse method 541
Williams syndrome 40
Wilms tumor 748, 748f
Wilson's disease 153, 154, 156, 162, 198, 199, 366
Wiskott-Aldrich syndrome 394
Wood's lamp, scalp under 439
Work-life balance 627
World Health Organization 69, 78, 139
Wrist, widening of 84, 84f
X
Xanthochromia, coexistence of 180
Xerophthalmia 81
classification of 82t
X-ray 299
abdomen 771f
with barium swallow 763f
Y
Yellow fever 128
vaccine 129
Yellow phosphorus 654656
Yersinia enterocolitica 357
Yolk sac tumor 332, 335
Z
Zellweger spectrum disorders 603
Zellweger syndrome 603, 611
Ziehel-Neelsen smear, sensitivity of 113
Zika syndrome, congenital 206
Zinc 655, 656
phosphide 654, 655
sulfate 8
Zipper entrapment 331
Zonisamide 55
×
Chapter Notes

Save Clear


NewbornCHAPTER 1

Contributors: Rhishikesh Thakre,
Naveen Jain
Reviewers: Shailaja Mane,
Anupama S Borker
  • 1.1 Neonatal Thrombocytopenia
  • 1.2 Neonatal Sepsis
  • 1.3 Prolonged Hyperbilirubinemia
  • 1.4 Hypoglycemia in Newborn
  • 1.5 Respiratory Distress Syndrome in Preterm
  • 1.6 Neonatal Shock
  • 1.7 Apnea of Prematurity
  • 1.8 Newborn Screening
  • 1.9 Neonatal Seizures2
1.1 NEONATAL THROMBOCYTOPENIA
 
DEFINITION
The “normal range” of platelets differ with gestation, but working definition of low platelets is 1.5 × 106/L.
 
ETIOLOGY
  • Sick baby
    • Sepsis—especially gram-negative
    • Necrotizing enterocolitis (NEC)
    • Perinatal asphyxia
    • Therapeutic hypothermia/severe hypothermia
    • Intrauterine infections—cytomegalovirus (CMV)
    • Fungal infections
  • Nonsick baby
    • Severe intrauterine growth restriction (IUGR)
    • Neonatal alloimmune thrombocytopenia (NAIT)
    • Maternal immune thrombocytopenia purpura (ITP)
    • Rare conditions: Large hemangioma with thrombocytopenia.
 
EPIDEMIOLOGY
  • Early onset (<72 hours): If clinical signs of bleeding are present—consider NAIT and CMV infections
  • Early onset (<72 hours): If no clinical signs of bleeding—consider maternal pregnancy-induced hypertension (PIH), maternal ITP
  • Late onset: Infections are most likely.
 
SIGNS AND SYMPTOMS
  • Skin bleeds in form of petechiae, puncture site bleeds
  • Bleed from mucosa: Endotracheal, gastric bleeds
  • Serious manifestations: Intracranial bleed
  • Serious manifestations: Bleeding and shock.
 
TREATMENT AND COURSE
  • Look for general condition and stabilize airway and breathing in a sick bleeding neonate
  • Look for shock and correct
  • Look for severe pallor and consider packed red blood cell transfusions.
The thresholds for platelet transfusions vary, but safe working guidelines are given in Table 1.1.1.
Table 1.1.1   Platelet threshold for transfusion.
Platelet threshold for transfusion
Setting
30,000
Sick neonate, no bleeding manifestation
30,000
Extreme preterm, no bleeding manifestation
50,000
Major invasive procedure and not bleeding
100,000
Surgery, neuroinvasive procedure—lumbar puncture
3Practical points regarding platelet transfusion:
  1. Platelets are stored at 22°C and should not be refrigerated
  2. Platelets are stored on an agitator in blood bank, they cannot be transfused long after they are issued
  3. There are not significant differences in single donor platelets and apheresis in most clinical situations.
 
DIFFERENTIAL DIAGNOSIS
Bleeding can be due to coagulation factor defects and other local factors.
 
DIAGNOSIS
  • Automated complete blood count
  • Confirmation of platelet clumping and morphology on peripheral blood film by pathologist
  • Antibody studies when NAIT is suspected
    • Neurosonogram/abdominal scan: Severe pallor/shock.
 
PROGNOSIS AND PREVENTION
  • Most babies with low platelets do not have severe bleeding
  • NAIT can result in severe fatal bleeding
  • In extreme preterm babies, intraventricular hemorrhage (IVH) and pulmonary hemorrhage can be fatal/associated with long-term morbidities.
1.2 NEONATAL SEPSIS
 
ETIOLOGY
The risk factors for early onset and late onset sepsis differ (Table 1.2.1). The predominant organism for neonatal sepsis, irrespective of timing of infection is Klebsiella pneumoniae in India. Other gram-negative rods (Escherichia coli, Pseudomonas spp, Acinetobacter spp) and Staphylococcus aureus are also major contributors.
Table 1.2.1   Risk factors for sepsis.
Early onset sepsis (<72 hours)
Late onset sepsis (>72 hours)
Intrapartum factors
Community factors
  • Unexplained preterm labor
  • Febrile mother
  • PROM > 24 hours
  • Preterm PROM
  • Prolonged labor/difficult labor
  • Foul liquor
  • Meconium-stained liquor in preterm
  • Apgar < 6 at 5 minutes
  • Prelacteal feeds
  • Poor hygiene
  • Poor cord care
  • Cultural practices
  • Top feeds
  • Prolonged NICU stay (>7 days)
  • Prolonged use of antibiotics
  • Invasive procedures
  • Total parenteral nutrition
  • Congested nursery
  • Prolonged ventilation
  • No enteral feeds
  • No breast milk feeding
  • Indwelling catheters
  • Gut surgery
4  
EPIDEMIOLOGY
  • An estimated one million newborns die from infections in developing countries
  • World Health Organization (WHO) estimates suggest that sepsis, pneumonia, tetanus and diarrhea cause 32% of neonatal deaths with high case fatality rates of 45%.
 
SIGNS AND SYMPTOMS
  • No single diagnostic sign or symptom for neonatal sepsis
  • May be asymptomatic or nonspecific signs: Irritability, drowsy, apnea, respiratory distress, poor perfusion, thermal instability, vomiting, poor feeding, seizures, etc.
  • Subtle markers: Core-axillary temperature mismatch, fluctuating temperature, unexplained tachycardia, changing body color, upcoming direct jaundice, unexplained metabolic acidosis
  • Severe sepsis: Sclerema, bleeding tendency, cyanosis, grunt, abdominal fullness or redness, persistent gastric residue, neck retractions, bulging fontanel, thrombocytopenia
  • YICSS Study identified seven clinical signs to predict possibility of sepsis in community settings (Table 1.2.2).
Table 1.2.2   Clinical markers for suspected sepsis (first week) (85% sensitivity and 75% specificity).
  • Fast breathing (respiratory rate >60 breaths per minute)
  • Severe chest in-drawing
  • Hyperthermia >37.5°C
  • Hypothermia <35.5°C
  • No movement or movement only on stimulation
  • Convulsions
  • Poor feeding
 
TREATMENT AND COURSE
 
Supportive Care
  • Nursing care: Minimal handling, minimize pricks, ensure skin integrity, change body posture, probe position every 4–6 hours, club interventions together, take pain control measures and ensure mother's participation in care of the newborn
  • Ensure normothermia. Target temperature of 36.5°C
    • Ensure normoxia. Target SpO2—88–94%
    • Ensure euvolemia. Ensure urine output of >1 cc/kg/hour
    • Ensure normotension
    • Ensure normoglycemia. Ensure blood sugar >50 mg%
    • Monitor every 3–4 hourly or as needed—sensorium, cry, activity, respiratory status (Down's score), circulatory status [temperature, heart rate (HR), pulse volume, respiratory rate (RR), urine output, color, extremity temperature, blood pressure, SpO2].
 
Definitive Care (Tables 1.2.3 and 1.2.4)
  • Antibiotics
  • Indicated for all sick infants and with positive sepsis screen
  • The choice of antibiotics depends upon site of infection, suspected organism, timing of infection, antibiotic sensitivity pattern and culture status5
  • Antibiotic therapy should be stopped after 36 hours if cultures are negative OR if two C-reactive protein (CRP) measurements are negative and if there are no further clinical signs of infection.
  • Intravenous immunoglobulin (IVIG) (500 mg/kg) use is restricted to severe sepsis on case by case basis
  • Management of shock. Fluid bolus should be considered on case by case basis if there is poor perfusion. Consider inotropes if the shock is fluid resistant. Dopamine is the drug of choice if the shock is hypotensive. Dobutamine is preferred if there is myocardial involvement. Consider increments in inotrope dose based on clinical response
  • Steroids are restricted to inotrope resistant shock.
Table 1.2.3   Antibiotic strategy.
Whom?
Symptomatic infants, positive sepsis screen
Which?
Empiric choice
Comments
EOS
Penicillin + aminoglycoside
Consider a third-generation cephalosporin (cefotaxime preferred) or carbapenem for meningitis
LOS
Vancomycin + aminoglycoside
  • Prefer aminoglycoside over cephalosporin to overcome resistance
  • Consider cephalosporin if meningitis suspected
  • Consider carbapenem if on third-generation cephalosporin
  • Consider amphotericin for fungemia
  • Alter therapy on culture results
  • Have an antibiotic exit policy if no organism is isolated
Drug doses
Birth weight < 2 kg mg/kg/day
Birth weight > 2 kg mg/kg/day
< 7 days
>7 days
< 7 days
>7 days
Ampicillin*
25-100 q12h
25-100 q8h
25-100 q8h
25-100 q6h
Penicillin G*
25,000-100,000 q12h
25,000-100,000 q8h
25,000-100,000 q8h
25,000-100,000 q6h
Gentamicin
4 q24h
4 q24h
5 q24h
5 q24h
Amikacin
7.5 q12h
7.5 q8h
10 q12h
10 q8h
Vancomycin
15 q12h
15 q8h
15 q12h
15 q8h
Cefotaxime
50 q12h/6h*
50 q8h/6h*
50 q12h/6h*
50 q8h/6h*
Piperacillin + Tazobactum
50-100 q12h
50-100 q8h
50-100 q12h
50-100 q12h
Higher dose for meningitis
Table 1.2.4   Management of sepsis.
Clinical status
Sepsis screen
Blood culture
Antibiotic duration
Diagnosis
Unstable
Negative
Negative or not done
7-10 days
Clinical sepsis or culture –ve sepsis
Stable
Positive
Negative
5-7 days
Probable sepsis
Unstable
Negative
Positive
10-14 days
Culture +ve sepsis
Unstable
Positive/Negative
Cerebrospinal fluid (CSF) positive
14-21 days
Sepsis with meningitis
6  
DIFFERENTIAL DIAGNOSIS
  • Viral infection
  • Metabolic (electrolyte imbalance, hypoglycemia, etc.)
  • Polycythemia
  • Surgical causes (tracheoesophageal fistula, congenital diaphragmatic hernia, intestinal obstruction, etc.)
  • Malformation (isolated cleft palate, congenital lung cyst, etc.)
  • Meconium aspiration
  • Inborn error of metabolism
  • Congenital heart defect.
 
DIAGNOSIS
  • Blood culture is gold standard for diagnosis of bacterial sepsis. Good practices to yield higher isolates on blood culture are:
    • At least 1 mL blood sample
    • Sample collected prior to antibiotic use
    • Preparation of the site with an antibacterial solution (alcoholic solutions of chlorhexidine, iodine, or povidone-iodine) and cleansing for 30 seconds or two consecutive cleansings
  • Cerebrospinal fluid (CSF) study if blood culture is positive or suspected meningitis
  • Sepsis screen (Table 1.2.5) is indicated if sepsis is doubtful. It is performed after 12 hours of admission and repeated 24–48 hours later. It is not a substitute for blood culture.
Table 1.2.5   Sepsis screen.
  • Total leukocyte count (TLC) < 5000 or > 20,000/cmm.
  • Neutropenia as per Manroe's chart (term) or Mouzinho chart (preterm)
  • I:T ratio > 0.2
  • Micro-erythrocyte sedimentation rate (ESR) > 15 mm
  • C-reactive protein (CRP) > 1 mg/dL
If more than 2 tests are positive infant should be treated with presumptive diagnosis of neonatal sepsis.
In Late onset sepsis evaluation in addition to above tests should include urine routine/culture and CSF study.
 
PROGNOSIS AND PREVENTION (TabLE 1.2.6)
Long-term follow-up of survivors is required due to risk of poor growth and poor neuro-developmental outcome.
Table 1.2.6   Potential best practices for infection prevention.
  • Ensure WHO ‘5 moments’ of hand hygiene
  • Early and frequent use of mother's own milk
  • Minimal handling
  • Ensure skin integrity while removing catheters, probes, adhesives.
  • Minimize duration of catheters, cannula, tubes and lines
  • Microbiologic surveillance and audit
  • Antibiotic stewardship program
7
1.3 PROLONGED HYPERBILIRUBINEMIA
 
DEFINITION
  • Jaundice beyond 14 days
  • Secondary to raised indirect or direct bilirubin (cholestasis: Direct fraction > 2 mg% or > 15% of total bilirubin).
 
ETIOLOGY
Table 1.3.1 shows causes of prolonged hyperbilirubinemia.
Table 1.3.1   Causes of prolonged hyperbilirubinemia
Indirect hyperbilirubinemia
  • Multifactorial (prematurity, bruising, cephalhematoma or cephalohematoma, polycythemia, delayed passage of meconium)
  • Breast milk jaundice
  • Ongoing hemolysis (ABO, Rh incompatibility, G6PD deficiency)
  • Congenital hypothyroidism
  • Occult infection (UTI, malaria)
  • Infantile hypertrophic pyloric stenosis
  • Genetic disorders (Crigler Najjar, Gilbert's syndrome)
Direct hyperbilirubinemia
  • Very low birth weight (multifactorial)
  • Inspissated bile syndrome (excessive hemolysis)
  • Sepsis (bacterial, fungal, viral, protozoal)
  • Obstruction in biliary tract (biliary atresia, choledochal cyst)
  • Hepatitis (toxoplasma, CMV, herpes, rubella, syphilis)
  • Drug induced (ceftriaxone, parenteral nutrition)
  • Metabolic conditions (congenital hypothyroidism, galactosemia, hereditary fructose intolerance, alpha-1 antitrypsin deficiency, tyrosinemia, cystic fibrosis, hemosiderosis)
  • Genetic disorders (Dubin-Johnson, Rotor syndrome)
  • In 25-30% cases, no specific etiology seen
 
EPIDEMIOLOGY
  • Up to 15% newborns develop prolonged jaundice
  • Common in preterm
  • Neonatal cholestasis: Affects 1 in 2500 live births. Constitutes 30% of hepatobiliary disorders in India. Average age of presentation is 3.5 weeks
  • Cholestasis: Idiopathic neonatal hepatitis (26%), extrahepatic biliary atresia (26%), infection (12%), associated with TPN (6.5%), metabolic disease (4.3%), α1-antitrypsin deficiency (4.1%), perinatal hypoxia/ischemia (4%).
 
SIGNS AND SYMPTOMS
  • Spectrum of presentation: Asymptomatic to acute liver cell failure, ascites, bleeding tendency and multiorgan dysfunction
  • First identify infant is well or sick and raised bilirubin is direct or indirect8
  • Cholestasis: High colored urine, clay stools, need urgent workup
  • Intrauterine infection (e.g. TORCH): Weight loss, pallor, hepatosplenomegaly, petechiae, ecchymoses, chorioretinitis, thrombocytopenia, intrauterine growth restriction (IUGR), congenital anomaly
  • Metabolic disorder: Consanguinity, previous siblings affected, abnormal body or urine odor, unexplained deaths, dysmorphism
  • Inherited hemolytic disorders, inborn errors of metabolism or genetic syndromes: Family history of jaundice
  • Fundus evaluation: It may give a clue.
 
TREATMENT AND COURSE
 
Indirect Hyperbilirubinemia
  • Phototherapy: Rarely indicated
  • Treatment: Directed towards cause.
  • Breast milk jaundice: Benign, self-limiting. No role of withholding breast feeds.
  • Congenital hypothyroidism: Early treatment can prevent intellectual delay.
 
Direct Hyperbilirubinemia
  • Urgent detection and management of surgical cause within eight weeks for better outcomes
  • Supportive care: Supplementation (Table 1.3.2)
  • Liver transplant is last option.
Table 1.3.2   Medications for cholestasis
Drug
Dose/day
Duration
Vitamin A
5000 IU
3 months after resolution of jaundice
Vitamin D 3
800-5000 IU
Vitamin E
100 mg
Vitamin K
2.5-5 mg twice weekly
Zinc sulfate
1 mg/kg
Till cholestasis resolves
Medium chain triglycerides
1-2 mL/kg
Calcium
100 mg/kg
Phosphorus
50 mg/kg
Ursodeoxy cholic acid
20 mg/kg, 2 divided doses
 
DIFFERENTIAL DIAGNOSIS
 
DIAGNOSIS
  • Breast milk jaundice: Diagnosis of exclusion
  • Basic screening: Hematocrit, retic count, direct Coombs test, peripheral blood smear, thyroid profile, urine culture9
  • Cholestasis: Elevated direct bilirubin USG, HIDA scan, liver biopsy or intraoperative cholangiogram.
 
Further Tests
Table 1.3.3 shows further tests.
Table 1.3.3   First-line tests for cholestasis.
For all
CBC, blood group, Direct coombs test, retic count, S electrolytes, urine microscopy, non-glucose reducing substances, S calcium, thyroid profile, USG abdomen after 4 h fast for gallbladder, choledochal cyst
Liver function
S bilirubin (direct/indirect), SGOT, SGPT, alkaline phosphatase, GGPT, albumin, cholesterol, triglycerides, coagulation screen
Sick infant
Plasma ammonia, lactate, pyruvate, blood gas, urinary pH, protein, ketones, chest X-ray, plasma, urine analysis
Suspected infection
Blood and urine culture, CRP, serology (IgM Toxoplasma, Rubella, CMV, Herpes), hepatitis A, B, C serology
Suspected metabolic disorder
Cystic fibrosis genetics, sweat test, galactose-1-phosphate uridyl transferase, alpha 1 antitrypsin level, phenotype, plasma, urine amino acids, urine organic acids (succinyl acetone), carnitine, acyl carnitine, iron, ferritin
Suspected obstruction
HIDA scan, liver biopsy/intraoperative cholangiogram
(CBC: complete blood count; CMV: cytomegalovirus; CRP: C-reactive protein; SGOT: serum glutamic oxaloacetic transaminase; SGPT: serum glutamic pyruvic transaminase; GGPT: Gamma-glutamyl transferase)
 
PROGNOSIS AND PREVENTION
  • Up to 60% babies with idiopathic neonatal hepatitis recover completely
  • Up to 30% newborns with cholestasis progress to liver cirrhosis, chronic liver disease death
  • Adverse prognostic features: Acholic stools, biliary features on liver biopsy, firm hepatomegaly, positive family history
  • Prompt diagnoses of treatable causes have better outcomes. Metabolic (galactosemia, tyrosinemia), endocrinal (congenital hypothyroidism, hypopituitarism), infections (malaria, congenital syphilis, toxoplasmosis, sepsis), surgical (choledochal cyst, biliary atresia).
1.4 HYPOGLYCEMIA IN NEWBORN
 
DEFINITION
  • Hypoglycemia is defined as low blood sugar; (and resultant) low “brain sugar” causes permanent damage to the neurodevelopment of the child
  • There is no single value of blood sugar that can define what is low for all situations.
    • In a healthy term baby with no risk factors—35 mg/dL
    • Sick babies (or on >10 mg/kg/minute of dextrose infusion) —60 mg/ dL
    • Pediatric Endocrine Society recommends values of 50 mg/dL in first 48 hours and 60 mg/dL after that
    • American Academy of Pediatrics (AAP) describes blood sugar level (BSL) less than 40 mg/dL in asymptomatic neonates10
The values at which this damage to brain may happen is dependent on:
  • Gestation of the baby
  • Comorbidities of brain (asphyxia, meningitis)
  • Intactness of blood sugar metabolism (body stores, feeding, insulin regulation and gluconeogenesis).
 
ETIOLOGY
Babies at-risk of hypoglycemia:
  • Sick neonates/all babies on intravenous fluids
  • Infant of diabetic mothers
  • Preterm neonates/post-term
  • Small and large for gestational age
  • Asphyxia
  • Transient hyperinsulinemia due to stress
  • Primary disorders of glucose metabolism
    • Primary hyperinsulinemia
    • Congenital adrenal hyperplasia
    • Inborn errors of metabolism—glycogen storage disease, medium chain acyl-CoA dehydrogenase deficiency.
 
EPIDEMIOLOGY
  • First 48 hours of life—Babies at risk (mentioned above) must be screened periodically 6th hourly or more often
  • All sick neonates must have blood sugar monitored as a part of the primary survey. Any hypoglycemia that is severe (needs intravenous fluids), symptomatic (lethargy, seizures, apnea, jitteriness), recurrent or persistent after 3 days of life must be considered pathological and evaluated for etiology.
 
SIGNS AND SYMPTOMS
Symptoms of hypoglycemia are grouped as:
  • Neuroglycopenic—lethargy, seizures, apnea
  • Adrenergic—jitteriness, sweating, tachycardia.
Note the setting that led to hypoglycemia like prematurity, low birth weight, infant of diabetic mother, sepsis, asphyxia, etc. as these determine the expected course of hypoglycemia.
 
TREATMENT AND COURSE
  • Asymptomatic babies with blood sugar values below “normal”, detected by screening, are offered breast milk (preferred)/formula milk and blood sugars measured every 15–30 minutes till blood sugar reach safe values
  • Symptomatic babies/babies with blood sugar <25 mg/dL are given a 2 mL/kg bolus of 10% dextrose, followed by 10% dextrose infusion at 80 mL/kg/day (6 mg/kg/minute). Blood sugars measured every 15–30 minutes till blood sugar reach safe values, the infusion is increased by 2 mg/kg/minute, if the sugar values are below “normal”. If dextrose infusion of 12.5% or more is required, a central line must be inserted11
  • The dextrose infusion is tapered every 6–12 hours, if the values are over 60 mg/dL
  • If dextrose infusion of 10 mg/kg/minute is required—hydrocortisone (or dexamethasone)
  • Diazoxide is used, if high glucose infusion rate (GIR) is required and blood sugar remains unstable. If still not responding, octreotide is tried. Nifedipine can be tried in most difficult cases
  • Glucagon can rapidly improve glucose levels in an emergency.
 
DIFFERENTIAL DIAGNOSIS
Hypoglycemia must be excluded in all babies with encephalopathy, in all sick babies.
 
DIAGNOSIS
  • Point of care testing by glucose oxidase method
    • Practical tips: The blood spot should be collected without contamination with antiseptic and should cover the sensing spot completely
  • Confirmation of low sugar is done in the lab using spectrophotometry. The sample must be processed without delay.
Values of blood sugar for intervention: 50 mg/dL.
 
PROGNOSIS AND PREVENTION
  • Symptomatic hypoglycemia—high risk of disability—seizures, intellectual disability, cortical visual impairment (typical area of injury is parieto-occipital lobes)
  • Asymptomatic hypoglycemia—much lower risk
  • Prevention involves supporting lactation and periodic monitoring in high risk neonates.
1.5 RESPIRATORY DISTRESS SYNDROME IN PRETERM
 
DEFINITION
Respiratory distress syndrome (RDS) refers to onset of respiratory distress (retractions, grunting, tachypnea) within 6 hours of birth in a preterm baby.
 
ETIOLOGY
  • Respiratory distress syndrome is a clinical diagnosis
    • Surfactant insufficiency due to prematurity
    • Congenital pneumonia
    • Transient tachypnea of newborns.
 
EPIDEMIOLOGY
  • Incidence of RDS is dependent on gestation
Gestation (weeks)
<28
28-32
>33
Babies with RDS (%)
60-80
30-40
<10
  • 12Male babies are more likely to have RDS
  • Antenatal steroids decrease RDS incidence and severity
  • Coexisting early onset neonatal sepsis can present as RDS (congenital pneumonia).
 
SIGNS AND SYMPTOMS
  • Retractions are the most important determinants of severity and actions to be taken [continuous positive airway pressure (CPAP)]
  • Grunting may be heard without stethoscope (severe) or only with stethoscope (mild)
  • Cyanosis (need for oxygen)
    • Mild—pink (saturation 90 or more) without supplemental oxygen
    • Moderate—cyanosis corrected with 30–40% oxygen by mask/hood box
    • Severe—saturation <90/cyanosis even with 30–40% oxygen
  • Tachypnea [respiratory rate (RR)] more than 80/minute (severe) and 60–80/minute (mild); RR is subject to errors, as babies have irregular breathing pattern
  • Decreased air entry (subjective); asymmetry of breath sounds may give more information
    • Some RDS scores include gestation
  • Severe RDS may present with apnea.
 
TREATMENT AND COURSE
Treatment options would depend on severity of respiratory distress, anticipated severity of illness and general condition of baby:
  • CPAP
    • Babies with moderate respiratory distress (retractions, grunt, cyanosis corrected with 30–40% oxygen)
    • Gestation more than 28 weeks
    • Good respiratory efforts, tone, perfusion; no apnea, not needing extensive resuscitation at birth (chest compression, medications)
    • Initiate CPAP in labor room with T-piece resuscitator, if preterm baby has signs of RD (some recommend prophylactic CPAP for extreme preterm babies)
  • INSURE— Intubate, give surfactant, extubate within 15 minutes and put back on CPAP— this is the best care plan for babies with severe RDS or those progressing in symptoms on CPAP
  • Intubation, mechanical ventilation—babies with recurrent apnea, cardiovascular instability
  • HHHFNC (heated humidified high flow nasal cannula) is inferior to CPAP as initial support for RDS; is equally effective in support of babies extubated after invasive ventilation for RDS
  • Oxygen by hood/mask must be used only transiently to assess babies with RDS, or while CPAP is being organized (if baby was not labor room CPAP/T-piece resuscitator).
Early use of CPAP and surfactant when indicated results in dramatic improvement of RDS. If babies are not off respiratory support, the following are considered:
  • Comorbidity—infection
  • Extreme preterm
  • Complications of respiratory support—air-leak or abdominal distension (CPAP belly).13
 
DIFFERENTIAL DIAGNOSIS
  • Congenital pneumonia
  • Transient tachypnea of newborn
  • Rarely—air leaks.
 
DIAGNOSIS
  • Clinical findings
  • Chest X-ray
    Mild-moderate: Air bronchogram, low volume lungs, haziness of cardiac and liver borders
    Severe: Air bronchogram, white-out (one cannot make out lung, heart and liver shadows as separate)
  • Arterial blood gas: Respiratory acidosis and hypoxia
  • Infection markers (blood culture) and CRP are negative.
 
PROGNOSIS AND PREVENTION
  • Respiratory distress syndrome resolves rapidly and completely if CPAP (and surfactant in some, mechanical ventilation in lesser) is started early and given effectively with good nursing care
  • Early enteral feeding, hypothermia and prevention of infection are key to good outcomes
  • Extreme preterm babies may evolve to bronchopulmonary dysplasia and may be respiratory support for very long duration; this is due to immaturity of lung.
1.6 NEONATAL SHOCK
  • Shock is a critical clinical disorder characterized by decreased end organ perfusion
  • It should be recognized before onset of hypotension (i.e. blood pressure below the 5th percentile for gestation and postnatal age) which is a late or advanced sign of shock.
 
ETIOLOGY
  • Hypovolemic shock
    • Blood loss, e.g. antepartum hemorrhage (e.g. abruptio placenta, placenta previa), twin to twin transfusion, bleeding due to vitamin k deficiency, slipped cord ligature, birth trauma, coagulation disorders, etc.
    • Fluid loss, e.g. vomiting, diarrhea
  • Distributive shock, e.g. septicemia, hydrops, toxic shock syndrome
  • Cardiogenic shock
    • Decreased myocardial contractility, e.g. myocarditis, electrolyte imbalance, drug toxicity
    • Structural heart disease, e.g. hypoplastic left heart, aortic stenosis, coarctation of aorta, transposition of great vessels, cardiomyopathy
    • Rhythm disorders, e.g. supraventricular tachycardia, congenital heart block
  • Obstructive shock, e.g. tension pneumothorax, pericardial effusion, postsurgery
  • Neurogenic shock, e.g. asphyxia, intracranial hemorrhage, meningitis, vascular malformation, space occupying lesions, etc.
  • Endocrine shock, e.g. congenital adrenal hyperplasia.14
 
EPIDEMIOLOGY
  • Shock is most prominent risk factor for death in neonatal sepsis
  • Shock is more common in late onset sepsis, preterm, very low birth weight (VLBW) babies.
 
SIGNS AND SYMPTOMS
  • No single sign pathognomic of shock (Table 1.6.1)
  • Poor perfusion needs to be recognized early
  • Hypotension: In compensated shock it may take hours for hypotension to develop
  • Cardiopulmonary failure develops in few minutes in hypotensive shock
  • Shock is a dynamic condition hence a trend of signs is far more informative.
Table 1.6.1   Clinical pointers for shock.
Poor perfusion (compensated shock)
Tachycardia, cold extremities, capillary refill time (CRT) > 3 seconds, drowsiness, tachypnea, weak pulses, oliguria
Hypotensive shock
BP < 5th percentile
Cardiogenic shock
Murmur, cardiomegaly, cardiac failure, unexplained hepatomegaly, absent pulses, cyanosis
Hypovolemic shock
Pallor, dehydration
Neurogenic shock
Tense fontanel, drowsiness, seizures, increasing head circumference, hypotonia, decreased cry or activity
Distributive shock
Core-axillary mismatch, pustules, umbilical foul discharge, omphalitis, sclerema
Endocrine shock
Hyperpigmented skin, ambiguous genitals
Obstructive shock
Sudden deterioration
 
TREATMENT
  • Supportive care: Strict asepsis, monitoring of vitals, normothermia (T 36.5oC), normoglycemia (B sugar > 50 mg%) normoxia (SpO2 > 88–94%).
  • Oxygen: Initiate and titrate dose based on pulse oximetry. Mechanical ventilation if inability to maintain SpO2 > 90% despite 100% oxygen.
  • Fluid bolus: Empiric bolus of 10 cc/kg of RL may be given. Avoid > 20 cc/kg if no history of fluid or blood loss. The routine use of fluid bolus is potentially harmful in preterm.
  • Inotropes (Table 1.6.2)
    • Dopamine: Most effective, first drug of choice
    • Dobutamine: If cardiac involvement
    • Epinephrine, norepinephrine: Nonresponsive shock
    • Milrinone: Reduces afterload in cardiac dysfunction
    • Treatment may be targeted based on status of patent ductus arteriosus (PDA), left ventricular output and systemic vascular resistance as assessed by functional echo.15
Table 1.6.2   Choice of drugs in shock.
Agent
Dose (μg/kg/min)
Receptors
Use
Risk
Dopamine
5-20
Δ1/Δ2 > β > α
Inotrope, septic shock
Peripheral vasoconstriction
Dobutamine
5-20
β1 > β2 > α
Contractility
Vasodilatation
Tachycardia
Epinephrine
0.05-2.5
β1 = β2 > α
Anaphylaxis, cardiogenic shock, septic shock
Ischemia
Hypertension
Norepinephrine
0.1-1.5
β1 > α > β2
Severe vasodilatation, hypotension
Ac idosis from poor perfusion, ischemic injury
Milrinone
0.3-0.7
Phosphodiesterase inhibitor
Inotrope vasodilation
Tachycardia vasodilation
  • Steroids: Inotrope resistant shock
  • Treatment of the cause (Table 1.6.3).
Table 1.6.3   Cause-specific treatment.
Hypovolemic shock
Fluid resuscitation, packed cell transfusion, fresh frozen plasma
Septic shock
Antibiotics, ventilation, IV immunoglobulins
Endocrine shock
Mineralocorticoids, glucocorticoids
Obstructive shock
Intercostal drain, pericardial tap, ventilation
Neurogenic shock
Fluid restriction, anticonvulsant, steroids
Cardiogenic shock
Prostaglandins, inotropes, digoxin, diuretics, ventilation, surgery
 
DIFFERENTIAL DIAGNOSIS
Asphyxia, metabolic (e.g. hypoglycemia, dyselectrolytemia), inborn error of metabolism, iatrogenic, drug induced, birth trauma.
 
DIAGNOSIS
  • Based on history, constellation of signs and clinical course
  • Hypotensive shock if low blood pressure
  • Bedside 2D echo provides physiologic cardiac status, blood flows shunt pathology
  • Specific investigations confirm the etiology.
 
PROGNOSIS AND PREVENTION
  • Best outcomes: If early recognition of poor perfusion and prompt action prior to development of hypotension.
  • Guarded prognosis: If two or more end organ damage.16
1.7 APNEA OF PREMATURITY
 
DEFINITION
Apnea of prematurity (AOP) is cessation of breathing for more than 20 seconds and/or accompanied by hypoxia or bradycardia by a premature newborn.
 
ETIOLOGY
  • Apnea of prematurity is a ‘diagnosis of exclusion’ in preterm newborns
  • Maturational disorder of central nervous system due to abnormal control of breathing
  • Common causes (Table 1.7.1).
Table 1.7.1   Common causes of apnea.
Day 1-2
Day 3-6
Late (> 7 days)
Hypothermia, hyperthermia, hypoxia, hypoglycemia
Asphyxia
Sepsis
Polycythemia
Anomalies of upper airway
Antepartum magnesium sulfate to mother
Hypocalcemia
Seizures
Sepsis
Patent ductus arteriosus (PDA)
Massive intraventricular hemorrhage (IVH)
Apnea of prematurity
Sepsis
Fungemia
Anemia
Gastroesophageal reflux (GER)
Necrotizing enterocolitis (NEC)
Inborn error of metabolism (IEM)
Bronchopulmonary dysplasia (BPD)
 
EPIDEMIOLOGY
Apnea of prematurity is inversely proportional to gestation, with incidence of 80% in <30 weeks, 50% at 30–32 weeks and 10% of at 34 weeks.
 
SIGNS AND SYMPTOMS
  • Significant apnea: Abrupt onset of periods of absent breathing (>20 sec) or less than 20 seconds with bradycardia or hypoxia
  • Classically seen on day 2–4 days (80%), rarely on day 1 or beyond 10 days
  • Infant otherwise well in between the episodes
  • Search for pathological causes if increase in frequency or severity:
    • Anemia (e.g. tachycardia, pallor)
    • Plethora, infection (e.g. rash, icterus, bleeding tendency, poor peripheral perfusion)
    • Heart disease (e.g. cyanosis, murmur, unexplained hepatomegaly, cardiomegaly, weak pulses)
    • Central nerve system (CNS) disorder (e.g. encephalopathy, hypo or hypertonia, seizures, tense anterior fontanel, color change)
    • Thermal instability, upper airway anomaly, work of breathing (e.g. bradypnea-tachypnea, chest indrawing, grunt, hypoxia)
    • Abdominal distention.17
 
TREATMENT AND COURSE
  • All newborns ‘at risk’: <34 weeks or <1800 g should be continuously monitored by pulse oximeter with saturation alarm and heart rate limits set (SpO2 88–94%)
  • Nil by mouth (NBM) for 24 hours of apneic spell.
 
General Measures
  • Neutral thermal environment
  • Nurse the baby in prone or lateral and head-up position
  • Ensure patency of airway (‘sniffing’ position, shoulder roll, suction)
  • Tactile stimulation—slapping feet, rubbing back
  • Oxygen supplementation, target SpO2: 88–94%
  • Support with positive pressure ventilation (PPV).
 
Drug Therapy
  • Medications if three or more significant episodes (Table 1.7.2)
Table 1.7.2   Drug therapy for AOP.
Caffeine citrate
Aminophylline
Status
Preferred choice
If caffeine not available
Prophylaxis
< 30 weeks
Rarely used
Loading dose
20-40* mg/kg, IV/PO
8 mg/kg, IV/PO
Maintenance dose
5-10 mg/kg/day, OD
1.5-3 mg/kg/day, 8-12 hrly
Half life
37-231 hrs
12-64 hrs
Side effects
Irritability
Tachycardia, vomiting, feeding intolerance, jitteriness seizures
Discontinuation
5 days apnea free or till 35 weeks postmenstrual age (PMA), whichever is first. Tapering doses
*Higher doses and a 12 hr dosing interval may be necessary in infants approaching term-equivalent age because of a more rapid caffeine metabolism.
  • Doxapram is rarely required for AOP. Contraindicated in 1st week of life or if bilirubin is high.
  • Respiratory support
    • Noninvasive respiratory support if apnea persists despite drugs and if there is spontaneous respiration, e.g. CPAP or noninvasive positive pressure ventilation (NIPPV) or high-flow nasal cannula
    • Intubation and mechanical ventilation. If there are no spontaneous respiration
  • Packed cell volume (PCV) transfusion
    • Hematocrit <25–30%
    • Increased frequency by 2–3 weeks of life and rarely persists beyond 37 weeks post- gestation.18
 
DIFFERENTIAL DIAGNOSIS
Hypoxia, sepsis, IVH, NEC, PDA, BPD, fungemia, electrolyte imbalance, thermal instability, hypoglycemia, hypocalcemia or inborn errors of metabolism.
 
DIAGNOSIS
  • Breathing pauses of >20 sec or associated with bradycardia or oxygen desaturations, clinical detection is too late and only severe or prolonged apneas can be detected
  • Baseline tests to rule out underlying causes: Sepsis screen, blood culture, blood sugar, serum calcium, serum electrolytes, cranial USG, 2D Echo, X-ray chest, ABG, etc.
 
PROGNOSIS AND PREVENTION
  • Apnea resolves in majority by 36 weeks (up to 44 weeks in < 28 weeks) postconceptual age
  • Apnea per se does not alter the neurologic outcome. Presence of comorbid conditions and complications decide the long-term outcome
  • Prevention of prematurity is the best measure
  • Awareness, early detection, meticulous monitoring
  • Infants less than 30 weeks may benefit from caffeine within 24 hours of age.
1.8 NEWBORN SCREENING
Screening: Proven, cost-effective coordinated, evidence-based strategy for a defined population.
 
METABOLIC SCREENING
  • About 25–30% unexplained deaths have a metabolic/genetic cause
  • Aim: Identify infants ‘at risk’ for metabolic disorders before onset of signs/symptoms
  • When: In full-term healthy infants at 72 hours of age. If tests done before 24 hours of age, repeat after two weeks
  • Sampling (Table 1.8.1)
Table 1.8.1   Sampling for metabolic screening.
Testing (generation)
Sample
Technique
Disorder
Cost (₹)
1st
Capillary heel prick
Radioimmunoassay
Single
300
2nd
Blood
Tandem mass spectrometer (TMS)
29
1-2000
3rd
Cord blood, urine
TMS, gas chromatography-mass spectrometry (GC-MS)
118
4000-5000
  • Strategy to screen
    • All newborns, in low resource settings (congenital hypothyroidism, congenital adrenal hyperplasia, G6PD deficiency)
    • ‘High risk’ newborns (phenylketonuria, homocystinuria, alkaptonuria, galactosemia, sickle-cell anemia, other hemoglobinopathies, cystic fibrosis, biotinidase deficiency, Maple syrup urine disease, medium-chain acyl-coenzyme A dehydrogenase deficiency (MCAD), tyrosinemia, fatty acid oxidation defects)
    • Screen for all disorders in all newborns in resource rich setting19
  • Interpretation
    • Invalid: Need to repeat test
    • Negative: Does not guarantee future onset of disease
    • Positive: Need for confirmation test. Does not indicate ‘disease’/need for therapy
  • Special conditions
    • Specimen: Take before blood transfusion
    • Premature/sick infants: Seven days of age
    • Newborn less than 32 weeks: Repeat test at 28th day/discharge
    • After starting feedings
    • Parenteral nutrition not contraindicated.
 
NEONATAL JAUNDICE SCREEN
  • Aim: Identify newborns ‘at risk’ for hyperbilirubinemia
  • Timing: At discharge
  • Strategy
    • Hour specific bilirubin nomogram (Fig. 1.8.1)
      • How: Plot bilirubin value on chart
      • Interpretation
      • Below low risk zone (<40th centile): Risk negligible, can be discharged
      • In intermediate zone (40–95th centile): 6.4% risk, assure follow-up re-evaluate 24 hours later
      • High risk zone (>95th centile), 39.5% risk. Repeat bilirubin 8 hours later.
      • Limitations: Not applicable— < 35 weeks, 0–24 hours, hemolysis
        zoom view
        Fig. 1.8.1: Hour-specific bilirubin nomogram.
    • 20Transcutaneous bilirubinometer (Fig. 1.8.2)
      • Place across forehead/sternum. Plot reading on nomogram
      • Limitations: Not applicable—<35 weeks, <24 hours of life, under phototherapy
        zoom view
        Fig. 1.8.2: Transcutaneous bilirubinometer.
    • Clinical risk assessment (Table 1.8.2).
    • Presence of one/more risk factors: Scheduled follow-up.
Table 1.8.2   Clinical risk assessment.
Risk factors:
  • Primi, gestation <37 weeks, visible jaundice
  • Weight loss (>10% birth weight or >3% daily)
  • Use of oxytocin, blood group incompatibility, e.g. Rh/ABO setting
  • G6PD deficiency, history of phototherapy to sibling
Scheduled follow-up:
  • One/more risk factors: Within next 24-48 hours
  • No risk factors: Next 48-72 hours
 
PULSE OXIMETER SCREEN
  • Aim: Detection of critical congenital heart defects (CCHD)
  • When: At discharge/after 24 hours of birth
  • Tool: Pulse oximeter with neonatal probe
  • How: Place pulse oximeter on right hand, foot
  • Interpretation (Table 1.8.3)
Table 1.8.3   Interpretation.
Pass
Indeterminate
Fail
SpO2 > 95% and <3% SpO2 difference between right hand and foot
SpO2 > 90-95% OR
>3% SpO2 difference right hand and foot
SpO2 < 90%
Follow-up clinically
Assess 1 hour later:
  • Interpret (pass, fail/indeterminate)
  • Indeterminate: Repeat 1 hour later
  • If still indeterminate or fail consult cardiologist
Cardiac consultation
Sensitivity 76.5% (95% CI 67.7-83.5), specificity 99.9% (99.7-99.9)
  • 21Conditions diagnosed: Cardiac lesions that require surgery or cardiac catheterization within first month of life to prevent death like hypoplastic left heart, pulmonary atresia, total anomalous pulmonary venous connection, transposition of great arteries, tetralogy of Fallot, tricuspid atresia, truncus arteriosus communis
  • Conditions missed: Ebstein's anomaly without right-to-left shunt, aortic stenosis without PDA, coarctation of aorta, interrupted aortic arch, pulmonary stenosis, left to right shunts
  • Limitations:
    • Normal screen at birth: Does not eliminate possibility of CCHD
    • Hypothermia, deep sleep or agitation may give abnormal readings
    • Different averaging time influence readings.
 
NEWBORN HEARING SCREEN
  • Aim: To identify hearing loss at earliest, intervene before 6 months of age
  • Test: Otoacoustic emission (OAE)
  • When: At discharge
  • For: Detection of cochlear function
  • Technique: A soft, disposable probe tip gently inserted into external ear canal. A sound stimulus at a moderate intensity level is generated. A miniature microphone within probe assembly detects OAE-related sound. The algorithms analyze recorded sound
  • Interpretation: Pass, refer/inconclusive.
    • Pass: Does not rule out hearing loss
    • Refer: Need detailed hearing assessment
    • Inconclusive: Repeat test
  • Advantages: Inexpensive, noninvasive, brief record time, objective, not affected by cognition, behavior, cooperation, motion, artifacts, technically easy, sedation, audiologist not required
  • Limitations
    • Background noise interferes testing, needs noiseless room
    • Debris, wax, fluid in middle ear interferes results
    • A screening tool, not a diagnostic modality
    • A normal test does not rule out late onset hearing loss
    • Does not provide, type, degree of hearing loss
    • Some false positives.
 
RETINOPATHY OF PREMATURITY SCREEN
  • Aim: Early detection of retinopathy to prevent visual loss, myopia, strabismus, visual impairment, permanent blindness
  • When: Day 30, for < 28 weeks/<1200 g at 2–3 weeks of age
  • Who: < 34 weeks/<2 kg/>34 weeks with unstable course
  • Preparation: Avoid feed 30 minutes prior, dilate pupils (topicamide 0.8% + phenylepherine HCl 5% diluted in 1:1 ratio with a tear substitute, methyl cellulose). Put 5 drops every 5 minutes × 3. Topical anesthetic eye drops (proparacaine), tear substitutes keep ready
  • Procedure: By trained ophthalmologist indirect ophthalmoscope, hand-held 20 D lens
  • Interpretation: Revised International classification of retinopathy of prematurity (ROP). (IRCOP, 2005)
  • Frequency of screening: By guidelines of IRCOP/ophthalmologist
  • When to stop screening: Zone III retinal vascularization without previous zone I/II ROP.22
 
SCREENING FOR DEVELOPMENTAL DYSPLASIA OF HIP
  • Aim: improve hip development in infancy, early childhood, to prevent subsequent functional impairment
  • When: At OPD visits
  • Whom: Breech position in utero, females firstborn, positive family history
  • Tests:
    • Barlow maneuver (adduct hip to midline, gently apply posterior force)
    • Ortolani maneuver (abduct hips, apply anterior-directed pressure at greater trochanters)
  • Interpretation: Positive, if femoral head subluxes, a clunk felt (Barlow) or relocates with a distinct clunk (Ortolani)
  • Diagnosis: Confirmation by static and dynamic USG study of hip if <6 months of age
  • Drawbacks
    • Sensitivity of maneuvers: 54%. Need tests to confirm
    • Severe dislocation: Not reducible, may not be picked up
    • Not applicable to infants, child
  • Sequelae of developmental dysplasia of hip (DDH): Osteoarthritis of hip
  • Endpoint of screening: Child reaches walking age.
1.9 NEONATAL SEIZURES
 
DEFINITION
Neonatal seizures:
  • Seizures in a neonate are manifestation of severe encephalopathy; rarely they are epilepsy of neonatal origin
  • Seizures are neurologic disturbances of sudden onset
    • Seizures may be motor (tonic, clonic), eye-movements—fixed gaze, apnea, abrupt changes in heart rate
    • Electroencephalography (EEG) monitoring, can confirm that the abrupt change in neurologic state is a seizure
    • Many abnormal movements in neonates mimic seizure
    • A few seizures may manifest only on EEG and may not be noticed clinically.
 
ETIOLOGY
  • Symptomatic seizures—secondary to severe encephalopathy
    • Hypoxic ischemic encephalopathy (HIE)
    • Perinatal stroke
    • Infections—meningitis, intrauterine infections
    • Intracranial hemorrhage—especially intraventricular hemorrhage in preterm
    • Hypoglycemia
    • Hypocalcemia, hypomagnesemia, hyponatremia
    • Congenital malformations of brain
  • Neonatal onset epilepsies.23
 
EPIDEMIOLOGY
  • The most common cause of seizures depends on state of perinatal care
  • In areas of high neonatal mortality (low-resources)—perinatal asphyxia is the most common, followed by infections
  • In areas of lowest neonatal mortality, stroke, malformations and metabolic disorders would be most common.
 
SIGNS AND SYMPTOMS
  • Commonest symptoms are abnormal movements—clonic movements, tonic posturing—the typical march of seizures in adults is often not seen
  • Abnormal eye movements—fixed gaze, blinking of eyes
  • Subtle movements—sucking, chewing and smacking movements of mouth
  • Apnea
  • Complete loss of tone
  • Autonomic changes—abrupt changes in heart rate, breathing pattern.
Seizures have multiple causes and hence the clinical syndrome is variable; most accept a seizure activity of 3 minutes or more as indication to treat.
 
TREATMENT AND COURSE
  • Stabilize airway, breathing
  • Check blood sugar and treat if low—2 mL/kg of dextrose followed immediately with dextrose infusion at 6 mg/kg/minute
  • Check ionized calcium (if report can be available immediately); if not, empirically treat with 2 mL/kg calcium gluconate push slowly with caution of risk of bradycardia and extravasation
  • Consider antiepileptic drug (AED), if seizures last 3 minutes or more after correction of glucose and calcium
  • Most frequently used 1st line AED is phenobarbitone
  • Recent concerns on long-term safety of phenobarbitone has led to evaluation of newer AED and levetiracetam seems to be a safe AED
  • Phenytoin is the first line AED in pediatric practice, hence, many use this as first line; which is equally effective and safe
  • If response to a single dose of AED is not noted, the next AED must be given after ensuring airway, breathing and circulation
  • Treat correctible factors like low sugar, low calcium, intracranial hemorrhage
  • Second AED commonly used are phenobarbitone, phenytoin, midazolam and many more
  • Need for second AED indicates severe underlying encephalopathy.
 
DIFFERENTIAL DIAGNOSIS
  • Many movements in neonates can mimic seizures
    • Jitteriness
    • Eye and mouth movements24
 
DIAGNOSIS
  • Clinical diagnosis is subject to errors; but, most clinicians do not have access to EEG when the seizure is suspected
  • EEG monitoring (or amplitude EEG) is available bedside in most advanced care centers and initiated on neonates with encephalopathy to make a better diagnosis
  • Lab tests for underlying cause—blood sugars, calcium, electrolytes, CSF examination
  • Screening for metabolic disorders
  • Imaging:
    • Neurosonogram: Ideal where IVH is common
    • MRI: To complete diagnosis of HIE
    • CT scan: Preferred for intracranial hemorrhage in term born babies, to detect calcification. CT has disadvantages of radiation exposure; but, it is faster than MRI and is used in unstable neonates.
 
PROGNOSIS AND PREVENTION
  • Depends mostly on the underlying cause
  • Late onset hypocalcemia mostly has favorable outcome
  • Hypoxic ischemic encephalopathy, hypoglycemia, malformation, infections are associated with more than 50% risk of neurodisability
  • Prognosis is poor if the EEG background is isoelectric or shows burst suppression in the interictal period
  • Preterm babies with seizures have poor prognosis
  • In HIE, early onset seizures (within 12 hours) and difficult to control seizures have poor outcomes.
BIBLIOGRAPHY
  1. Thakre R, Murki S. Protocols in Neonatology: Indian Academy of Pediatrics: Neonatology Chapter, 2nd edition. Jaypee Brothers Medical Publishers,  New Delhi, 2019.
  1. Murki S, Thakre R. OSCE in Neonatology: A Guide Book. Indian Academy of Pediatrics: Neonatology Chapter, 1st edition. Jaypee Brothers Medical Publishers,  New Delhi, 2017.