Algorithms inpostgraduatebooks.jaypeeapps.com/pdf/Pediatrics/Algorithms_In_Pediatrics.pdfJ.P....

Algorithms in

PediatricsEditors

anand s Vasudev DNB D Ped DCP MNAMS MICP (USA) FIAP FIMSASenior Consultant, Pediatric Nephrologist

Indraprastha Apollo and Max HospitalNew Delhi, India

Nitin K shah MD DCH DNBProfessor and Consultant Pediatrician

PD Hinduja National Hospital and Medical Research Centre

Honorary HematoncologistBJ Wadia Hospital for Children

Lions HospitalMumbai, Maharashtra, India

Foreword

Pramod Jog

New Delhi | London | Panama

The Health Sciences Publisher

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Jaypee Brothers Medical Publishers (P) Ltd

HeadquartersJaypee Brothers Medical Publishers (P) Ltd4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314Email: [email protected]

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Algorithms in Pediatrics / Anand S Vasudev, Nitin K Shah

First Edition: 2017

ISBN: 978-93-5152-160-0

Printed at

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Contributors

Editors

sEction Editors

Piyali Bhattacharya DCH MD FCCM PGDMLS

Specialist Sanjay Gandhi Post Graduate Institute of Medical SciencesLucknow, Uttar Pradesh, India

Amar J chitkara MD DNBHeadDepartment of PediatricsMax Superspeciality HospitalNew Delhi, India

rajesh r chokhani MD DCH FRCPCHConsultantMumbai, Maharashtra, India

Jaydeep choudhury DNB MNAMSAssociate ProfessorDepartment of PediatricsInstitute of Child HealthKolkata, West Bengal, India

neelu A desai MD DNBConsultantDepartment of Pediatric NeurologyPD Hinduja National Hospital and Medical Research CentreMumbai, Maharashtra, India

Anand s Vasudev DNB D Ped DCP MNAMS MICP (USA) FIAP FIMSA Senior Consultant, Pediatric NephrologistIndraprastha Apollo and Max HospitalNew Delhi, India

nitin K shah MD DCH DNBProfessor and Consultant PediatricianPD Hinduja National Hospital and Medical Research CentreHonorary HematoncologistBJ Wadia Hospital for Children Lions HospitalMumbai, Maharashtra, India

Pankaj V deshpande MRCP MD DCH FCPSConsultantDepartment of NephrologyPD Hinduja National Hospital andMedical Research CentreMumbai, Maharashtra, India

Anaita Udwadia Hegde MD MRCPCH Consultant Department of Pediatric NeurologyJaslok Hospital and Research CenterBreach Candy Hospital TrustBai Jerbai Wadia Hospital for ChildrenMumbai, Maharashtra, India

Vaman V Khadilkar MD DNB MRCP DCHPediatric EndocrinologistJehangir HospitalPune, Maharashtra, India Bombay HospitalMumbai, Maharashtra, India

Praveen Khilnani MD FICCM FSICCM FAAP FCCM

DirectorPediatric Critical Care Services and Fellowship ProgramBLK Superspeciality HospitalNew Delhi, India

PICU Mediclinic City HospitalDubai, UAE

Vikas Kohli MD FAAP FACCFetal, Neonatal, Pediatric CardiologistDirectorDelhi Child Heart Center New Delhi, India

Anurag Krishna MCh FAMSDirectorDepartment of Pediatrics and Pediatric SurgeryMax Institute of Pediatrics, Max HealthcareNew Delhi, India

shyam Kukreja Head Department of Pediatrics Max Superspeciality HospitalNew Delhi, India

Anjali Kulkarni MD FRCPCHHeadDepartment of Pediatrics and NeonatologySir HN Reliance Foundation HospitalMumbai, Maharashtra, India

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Algorithms in Pediatrics

Ashish Mehta MD DCHConsultant and DirectorArpan Newborn Care Centre Pvt LtdAhmedabad, Gujarat, India

rujuta Mehta MS DNBConsultant Balabhai Nanavati HospitalJaslok Hospital and Research Centre Shushrusha HospitalHead Department of Pediatric Orthopedics Bai Jerbai Wadia Hospital for ChildrenMumbai, Maharashtra, India

Vibhu Mendiratta MDConsultant and ProfessorDepartment of Dermatology and STDLady Hardinge Medical College and Associated HospitalsNew Delhi, India

taral V nagda MS DNB DOrthConsultant Department of Pediatric Orthopedics PD Hinduja National Hospital andMedical Research Centre, Saifee Hospital, Jupiter Hospital Mumbai, Maharashtra, India

MKc nair Professor and Vice ChancellorKerala University of Health Sciences and Founder Director Child Development CentreThrissur, Kerala, India

Priyankar Pal MDAssociate Professor and Head Department of PediatricsInstitute of Child HealthKolkata, West Bengal, India

Usha Pratap MD MRCPSenior ConsultantDepartment of Pediatric Cardiology Deenanath Mangeshkar HospitalPune, Maharashtra, India

Girish raheja MSSenior Consultant and Academic Coordinator Indraprastha Apollo HospitalNew Delhi, India

AtK rau MD DHAProfessor and InchargeDepartment of PediatricsMS Ramaiah Medical CollegeBangalore, Karnataka, India

Gr sethi MDFormerly HeadDepartment of PediatricsMaulana Azad Medical CollegeNew Delhi, India

rasik s shah MChSection InchargeDepartment of Pediatric Surgery PD Hinduja National Hospital and Medical Research CentreMumbai, Maharashtra, India

Anand K shandilya MD DCH FRCPCHConsultantDepartment of PediatricsDr Anand’s Hospital For ChildrenMumbai, Maharashtra, India

Anupam sibal MD FIMSA FIAP FRCP FRCPSenior Consultant Department of Pediatric Gastroenterology and Hepatology Indraprastha Apollo Hospitals New Delhi, India

Varinder singh MD FRCPCH Director ProfessorDepartment of PediatricsLady Hardinge Medical College and Kalawati Saran Children’s HospitalNew Delhi, India

tanu singhal MD MScConsultant, Department of PediatricsKokilaben Dhirubhai Ambani HospitalMumbai, Maharashtra, India

soonu Udani MDPediatric Intensivist Section Head Pediatrics PD Hinduja National Hospital and Medical Research CentreMumbai, Maharashtra, India

Vrajesh Udani MDConsultantDepartment of Pediatric NeurologyPD Hinduja National Hospital and Medical Research CentreMumbai, Maharashtra, India

shashi Vashisht MSProfessor and HeadDepartment of OphthalmologyDr Ram Manohar Lohia HospitalNew Delhi, India

Anju Virmani MD DNBSenior Consultant, Apollo, Max, Pentamed and Sundar Lal Jain HospitalNew Delhi, India

surender K Yachha MD DMProfessor and HeadDepartment of Pediatric GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknow, Uttar Pradesh, India

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Kochurani Abraham DCHSenior RegistrarDepartment of PediatricsJehangir HospitalPune, Maharashtra, India

Mohan K Abraham MS MChProfessor and HeadDepartment of Pediatric SurgeryAmrita Institute of Medical SciencesKochi, Kerala, India

Bharat Agarwal MD DChHeadDepartment of Hemato-Oncology BJ Wadia Children HospitalMumbai, Maharashtra, India

Gautam s Agarwal MChPrincipal ConsultantDepartment of Pediatric SurgeonMax Super Speciality HospitalNew Delhi, India

Manjari Agarwal MDAttending ConsultantDepartment of Pediatric RheumatologyInstitute of Child Health Sir Ganga Ram HospitalNew Delhi, India

Mridul Agarwal MD FNBConsultant Department of Pediatric Cardiac Sciences, Sir Ganga Ram HospitalNew Delhi, India

Mandar Agashe MSConsultant, Centre for Pediatric Orthopedic Care, Dr Agashe’s HospitalMumbai, Maharashtra, India

Anju Aggarwal MD FIAPAssociate ProfessorDepartment of PediatricsUniversity College of Medical Sciences and Guru Tegh Bahadur HospitalNew Delhi, India

neeraj Aggarwal MD FNHConsultant, Department of Pediatric Cardiac Sciences, Sir Ganga Ram HospitalNew Delhi, India

satish K Aggarwal MS MChSenior ConsultantDepartment of Pediatric SurgerySir Ganga Ram HospitalNew Delhi, India

Atul Ahuja MSSenior Consultant Department of ENT and Head and Neck Surgery Indraprastha Apollo HospitalNew Delhi, India

ira E Almeida DCH MD DNB PG-DAPSenior PediatricianDepartment of PediatricsHospicio HospitalMargao, Goa, India

Parmanand GK Andankar DCH DNBPediatric Intensivist Wadia Children HospitalConsultant Pediatric and Neonatal Intensivist Jupiter and Bethany HospitalThane, Maharashtra, India

Alaric J Aroojis MS DNB FCPSConsultantDepartment of Pediatric OrthopedicsKokilaben Dhirubhai Ambani Hospital and Bai Jerbai Wadia Hospital for ChildrenMumbai, Maharashtra, India

Priyanka Arora MSAssistant ProfessorDepartment of OphthalmologyDayanand Medical College and HospitalLudhiana, Punjab, India

shreedhara Avabratha K MD DNBProfessor Department of PediatricsFather Muller Medical CollegeMangalore, Karnataka, India

sanjay M Bafna MDSenior Consultant and HeadDepartment of PediatricsJehangir Hospital Pune, Maharashtra, India

Vibha s Bafna MD DCHSenior Consultant Department of PediatricsJehangir HospitalPune, Maharashtra, India

Arvind s Bais MS FIMSASenior ConsultantDepartment of ENTIndian Spinal Injury HospitalNew Delhi, India

naveen Bajaj DM MD Consultant, Department of NeonatologyDeep HospitalLudhiana, Punjab, India

Anurag Bajpai MD FRACPConsultant, Department of Pediatric and Adolescent Endocrinology Regency Hospital LimitedKanpur, Uttar Pradesh, India

Minu Bajpai MS MCh PhD FRCSProfessorDepartment of Pediatric SurgeryAll India Institute of Medical SciencesNew Delhi, India

chandra s Bal ProfessorDepartment of Nuclear MedicineAll India Institute of Medical SciencesNew Delhi, India

Padma Balaji MDJunior ConsultantKanchi Kamakoti Childs Trust and Childs Trust Medical FoundationChennai, Tamil Nadu, India

suma Balan MD MRCP CH CCSTConsultant Department of PediatricsAmrita Institute of Medical SciencesKochi, Kerala, India

indira Banerjee MD DNB MRCPCHTrainee, Department of Pediatric Cardiology, Rabindranath Tagore International Institute of Cardiac SciencesKolkata, West Bengal, India

contriBUtinG AUtHors

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sushmita Banerjee DCH MSc MRCPI FRCPCH

ConsultantDepartment of Pediatric Nephrology Calcutta Medical Research Institute Kolkata, West Bengal, India

rahul P Bhamkar DNB DCH MNAMSAssociate ConsultantDepartment of PediatricsSir HN Reliance Foundation Hospital Mumbai, Maharashtra, India

Vidyut Bhatia MDConsultantDepartment of Pediatric Gastroenterology and HepatologyIndraprastha Apollo Hospitals New Delhi, India

Veereshwar Bhatnagar MS MCh ProfessorDepartment of Pediatric SurgeryAll India Institute of Medical SciencesNew Delhi, India

sagar Bhattad MDSenior ResidentDepartment of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarh, India

reeta Bora MD DMAssociate Professor and Incharge of Neonatal UnitDepartment of PediatricsAssam Medical College Dibrugarh, Assam, India

sudha r chandrashekhar MD ESPEProfessorDepartment of PediatricsBai Jerbai Wadia Hospital for Children and Seth GS Medical CollegeMumbai, Maharashtra, India

Anirban chatterjee MS DNB MNAMSSenior Consultant Department of OrthopedicsMedica Superspecialty HospitalKolkata, West Bengal, India

Jasodhara chaudhuri MD MRCPCHRMO-cum-Clinical TutorDepartment of Pediatric MedicineMedical CollegeKolkata, West Bengal, India

Hitesh B chauhan MS Pediatric Orthopedic SurgeonDepartment of Pediatric OrthopedicRainbow Superspeciality Hospital and Children’s Orthopedic CentreAhmedabad, Gujarat, India

deepak chawla MD DMAssociate ProfessorDepartment of PediatricsGovernment Medical College HospitalChandigarh, India

Harshika chawla MBBSPostgraduate ResidentDepartment of OphthalmologyPostgraduate Institute of Medical Education and Research and Dr Ram Manohar Lohia HospitalNew Delhi, India

dinesh K chirla MD DM MRCPCHConsultant Department of NeonatologyRainbow Children’s HospitalHyderabad, Telangana, India

sushma P desai DCH MD PGDAPCounsellerGopi Children and Orthopedic Hospital and Adolescent Speciality ClinicSurat, Gujarat, India

Vaishali r deshmukh DCH DNB PGD-AP

Consultant and In-ChargeNine-to-Nineteen ClinicDeenanath Mangeshkar Hospital and Research Center Pune, Maharashtra, India

taru dewan MS FRCSEdAssociate ProfessorDepartment of OphthalmologyPostgraduate Institute of Medical Education and Research and Dr Ram Manohar Lohia HospitalNew Delhi, India

Arjun A dhawale MS DNB MRCSEdSurgeon, Department of Orthopedics and Spine SurgerySir HN Reliance Foundation Hospital and BJ Wadia Hospital For ChildrenMumbai, Maharashtra, India

dhulika dhingra MDAssistant ProfessorDepartment of PediatricsChacha Nehru Bal ChikitsalayaNew Delhi, India

Vinod Gunasekaran MD FIAPClinical Assistant, Institute of Child HealthSir Ganga Ram hospital New Delhi, India

Vikram Gagneja DNB FNB FCCMConsultant Pediatrician and Intensivist Gagneja Speciality Clinic New Delhi, India

suma Ganesh MS DNBEConsultant and Head Department of Pediatric Ophthalmology and StrabismusDr Shroff’s Charity Eye Hospital New Delhi, India

niti Gaur MDSenior ResidentDepartment of DermatologyLady Hardinge Medical College and Associated HospitalsNew Delhi, India

Paula Goel MD PGDAP PGDMLSConsultant and DirectorFayth Clinic Mumbai, Maharashtra, India

Anju Gupta MDAssociate ProfessorDepartment of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarh, India

sailesh G Gupta MD DCHConsultantDepartment of Pediatrics and Neonatology, Ashna Childrens Hospital and Arushee Childcare HospitalMumbai, Maharashtra, India

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shalu Gupta MDProfessor, Department of PediatricsLady Hardinge Medical College and Kalawati Saran Children’s HospitalNew Delhi, India

supriya Phanse Gupte MD PDCCLeeds Royal InfirmaryUnited Kingdom

omkar P Hajirnis MD DNB MRCPCHPediatric Neurologist Department of Pediatric NeurologyBhaktivedanta Hospital and Research Centre, Dr LH Hiranandani HospitalRajiv Gandhi Medical College and CSM HospitalMumbai, Maharashtra, India

Manisha Halkar MD DNBConsultant, Department of NeonatologyMeenakshi HospitalsBangalore, Karnataka, India

Aru c Handa Senior ConsultantDepartment of ENT and Head Neck Surgery Medanta Medicity Gurgaon, Haryana, India

Kumud K Handa MS DNB MNAMSDirector and Head Department of ENT and Head Neck SurgeryMedanta Medicity Gurgaon, Haryana, India

rashna d Hazarika MD Senior Consultant and Chief Department of Pediatrics, Pediatric and Neonatal Intensive CareMidland Hospital and Rigpa Children’s ClinicGuwahati, Assam, India

ira J Holla MBBSJunior ResidentDepartment of PediatricsLok Nayak Jai Prakash Narayan HospitalNew Delhi, India

ram G Holla MD DMSenior ConsultantDepartment of Neonatology and Pediatrics, Adiva HospitalsNew Delhi, India

Aspi J irani MD DCHPediatrician, Department of PediatricsNanavati Super Speciality HospitalMumbai, Maharashtra, India

nurul islam MD DNBConsultant, Pediatric Cardiology Mission HospitalDurgapur, West Bengal, India

Barath Jagadisan MD PDCCAssociate Professor Department of PediatricsJawaharlal Institute of Postgraduate Medical Education and ResearchPondicherry, India

Ashish Jain MD DNB DMAssistant ProfessorDepartment of NeonatologyMaulana Azad Medical CollegeNew Delhi, India

naveen Jain DM Coordinator, Department of NeonatologyKerala Institute of Medical SciencesTrivandrum, Kerala, India

shikha Jain MSMedical OfficerDepartment of OphthalmologyDr Ram Manohar Lohia HospitalNew Delhi, India

Manisha Jana Assistant ProfessorDepartment of RadiodiagnosisAll India Institute of Medical SciencesNew Delhi, India

Kana r Jat MD FCCP MNAMSAssistant ProfessorDepartment of PediatricsAll India Institute of Medical SciencesNew Delhi, India

nameet Jerath MDSenior Consultant, Department of Pediatric Critical Care and Pulmonology, Indraprastha Apollo HospitalNew Delhi, India

Ganesh s Jevalikar MD DNB PDCCConsultant, Department of Endocrinology and DiabetesMedanta The MedicityGurgaon, Haryana, India

nachiket M Joshi MBBSResidentDepartment of General SurgeryPD Hinduja National Hospital and Medical Research CentreMumbai, Maharashtra, India

nandkishor s Kabra DM MD DNB MScDirector, Department of NeonatologySurya Mother and Child CareMumbai, Maharashtra, India

Veena Kalra ConsultantDepartment of Pediatric NeurologyAll India Institute of Medical SciencesNew Delhi, India

Akshay Kapoor MDConsultantDepartment of Pediatric Gastroenterology and HepatologyIndraprastha Apollo Hospitals New Delhi, India

Gauri Kapoor MD PhD DirectorDepartment of Pediatric Hematology OncologyRajiv Gandhi Cancer Institute and Research CentreNew Delhi, India

dasmit s Khokar MS MCh FIAPSProfessor Department of Pediatric SurgeryBJ Medical College and Sassoon General HospitalsPune, Maharashtra, India

Vinayan KP MD DCH DNB DMProfessor and HeadDepartment of NeurologyAmrita Institute of Medical SciencesKochi, Kerala, India

Venkatadass Krishnamoorthy MS DNBConsultant, Department of OrthopedicsGanga HospitalCoimbatore, Tamil Nadu, India

rakesh Kumar ProfessorDepartment of Nuclear MedicineAll India Institute of Medical SciencesNew Delhi, India

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rashmi Kumar Professor and HeadDepartment of PediatricsKing George HospitalLucknow, Uttar Pradesh, India

sathish Kumar MD DCHProfessor and ConsultantDepartment of Pediatrics Christian Medical CollegeVellore, Tamil Nadu, India

ritabrata Kundu MD FIAPProfessor, Department of PediatricsInstitute of Child Health Kolkata, West Bengal, India

PA M Kunju MD DMProfessor and Head Department of Pediatric NeurologyGovernment Medical CollegeTrivandrum, Kerala, India

Lokesh Lingappa MD DM MRCPCHConsultant, Department of Pediatric Neurology, Rainbow Children’s Hospital Hyderabad, Telangana, India

Gaurav Mandhan MD FIAP Associate ConsultantDepartment of NeonatologyMax Super Specialty HospitalNew Delhi, India

Mamta V Manglani MD DCHProfessor and HeadDepartment of PediatricsLokmanya Tilak Municipal Medical College and General HospitalMumbai, Maharashtra, India

Mukta Mantan MD DNBProfessor, Department of PediatricsMaulana Azad Medical College New Delhi, India

Manoj G Matnani MD PGDVES PGDMDPN PGDVIH PGDCH

ConsultantDepartment of Pediatric NephrologyKEM Hospital, Jehangir HospitalPune, Maharashtra, IndiaBombay HospitalMumbai, Maharashtra, India

John Matthai DCH MD FAB FIAPProfessor and HeadDepartment of PediatricsPSG Institute of Medical Sciences Coimbatore, Tamil Nadu, India

Puthezhath sn Menon MD MNAMS FIAP FIMSA

Consultant and HeadDepartment of Pediatrics Jaber Al-Ahmed Armed Forces Hospital Kuwait, Kuwait

Bhavesh M Mithiya MD Dip (Pediatrics)

Consultant Department of PediatricsJupiter Hospital Kotagiri Medical Fellowship HospitalThane, Maharashtra, India

Aparajita Mitra MChSenior ResidentDepartment of Pediatric SurgeryAll India Institute of Medical SciencesNew Delhi, India

Monjori Mitra DCH DNB FIAPAssociate ProfessorDepartment of Pediatrics MedicineInstitute of Child HealthKolkata, West Bengal, India

rakesh Mondal MD DNB PDSR MNAMS MRCPCHI

ProfessorDepartment of Pediatric MedicineMedical College KolkataKolkata, West Bengal, India

Jayashree A Mondkar MD DCHProfessor and HeadDepartment of NeonatologyLokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical CollegeMumbai, Maharashtra, India

Anil K Monga MS DORL FCPSSenior Consultant Department of Otorhinolaryngology and Head Neck Surgery Sir Ganga Ram HospitalNew Delhi, India

Uday Monga MS FAGESenior ResidentDepartment of Otorhinolaryngology and Head Neck SurgeryUday ENT HospitalNew Delhi, India

sangeeta s Mudaliar DNB MRCPCHConsultantDepartment of Hemato-OncologyB J Wadia Children HospitalMumbai, Maharashtra, India

surpreet Bs nagi DCHConsultantDepartment of PediatricsDr Anands Hospital for ChildrenMumbai, Maharashtra, India

Premal naik MS DNBHon. Orthopedic Surgeon NHL Municipal Medical College Director, Rainbow Superspeciality HospitalAhmedabad, Gujarat, India

ruchi nanawati MDProfessor and Head, Department iof Neonatology, Seth GS Medical College and KEM HospitalMumbai, Maharashtra, India

narendra r nanivadekar MD DCH DNBConsultant, Department of PediatricsAster Aadhar HospitalKolhapur, Maharashtra, India

nikita MD DNBSenior Resident Department of Dermatology and STDLady Hardinge Medical College and Associated HospitalsNew Delhi, India

somashekhar M nimbalkar MDProfessorDepartment of PediatricsPramukhswami Medical CollegeKaramsad, Gujarat, India

raghupathy Palany BSc MD DCH FRCPProfessorIndira Gandhi Institute of Child HealthBangalore, Karnataka, India

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nitin Pant MS MChAssistant Professor Department of Pediatric SurgeryKalawati Saran Children’s HospitalLady Hardinge Medical CollegeNew Delhi, India

Ankit Parakh MD DNB MNAMSConsultantDepartment of Pediatric PulmonologyDr BL Kapur Memorial HospitalNew Delhi, India

Ketan P Parikh MS MChConsultant Pediatric Surgeon Department of Pediatric SurgeryJaslok HospitalMumbai, Maharashtra, India

Mandar B Patil DCH DNBAssistant ProfessorDr DY Patil Medical CollegeKolhapur, Maharashtra, India

sandeep A Patwardhan MS Orth D OrthProfessor Department of Pediatric OrthopedicsSancheti InstitutePune, Maharashtra, India

sarah Paul DCH MDProfessor Department of PediatricsPSG Institute of Medical SciencesCoimbatore, Tamil Nadu, India

ranjan K Pejaver FRCP FRCPCH FIAP FNNFProfessor, Department of NeonatologyKempegowda Institute of Medical SciencesChief Neonatologist, Meenakshi HospitalsBangalore, Karnataka, India

Preetham K Poddutoor Dch DNBConsultant, Department of Intensive Care, Rainbow Children’s HospitalHyderabad, Telangana, India

suhas V Prabhu MD DCH MNAMSVisiting Consultant Department of PediatricsPD Hinduja Hospital and Medical Research CentreMumbai, Maharashtra, India

Baldev s Prajapati MD DPed FIAP FICMCH MNAMS

ProfessorDepartment of PediatricsGCS Medical College, Hospital and Research CentreAhmedabad, Gujarat, India

rajal B Prajapati MD DPedProfessorDepartment of PediatricsSheth V S General Hospital and AMC MET Medical CollegeAhmedabad, Gujarat, India

Prema raghunathan DNB PGDAPProfessorDepartment of PediatricsRajarajeswari Medical CollegeBangalore, Karnataka, India

sarbani s raha MDConsultant Child Neurology and Epilepsy ClinicVadodara, Gujarat, India

devinder rai MSVice ChairmanDepartment of ENTSir Ganga Ram HospitalNew Delhi, India

Anand P rao MD DNBConsultant Department of Pediatric RheumatologyManipal HospitalBengaluru, Karnataka, India

narendra rathi MD DNB MNAMS FIAPConsultant, Department of Pediatrics Smile Institute of Child HealthAkola, Maharashtra, India

Aarathi r rau MDProfessor, Department of Pathology MS Ramaiah Medical CollegeBangalore, Karnataka, India

suyodhan A reddy MCh DNBAssociate ProfessorDepartment of Pediatric SurgeryBJ Wadia Hospital for ChildrenMumbai, Maharashtra, India

Arun G roy MD DMProfessorDepartment of NeurologyAmrita Institute of Medical SciencesKochi, Kerala, India

tapas K sabui MDProfessor Department of Pediatric MedicineRG Kar Medical College Kolkata, West Bengal, India

Anupam sachdeva MD DCHChariman, Institute of Child HealthSir Ganga Ram HospitalNew Delhi, India

Abhijeet saha MD IMS BHUAssociate ProfessorDepartment of Pediatrics Post Graduate Institute of Medical Education and ResearchDr Ram Manohar Lohia HospitalNew Delhi, India

Bhaskar saikia MDConsultantMax Superspeciality HospitalNew Delhi, India

VK sairam AB (Ped) AB (Ped. Neph)Pediatric NephrologistKanchi Kamacoti Childs Trust HospitalChennai, Tamil Nadu, India

dilip samal Senior Resident, Department of ENT and Head Neck Surgery Medanta MedicityGurgaon, Haryana, India

Jayanth s sampath MSc FRCSEdConsultant and DirectorBangalore Institute of Movement Research and Analysis Bangalore, Karnataka, India

Viraj V sanghi MD DNBConsultant, Department of NeurologyBombay Hospital and Medical Research CentreSaifee HospitalIka Children’s CentreMumbai, Maharashtra,India

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sarita sanke MDPostgraduateDepartment of Dermatology and STDLady Hardinge Medical CollegeNew Delhi, India

naveen sankhyan Assistant ProfessorDepartment of Pediatric NeurologyPostgraduate Institute of Medical Education and ResearchChandigarh, India

Vijaya sarathi MD DMAssistant ProfessorDepartment of EndocrinologyVydehi Institute of Medical Sciences and Research CenterBengaluru, Karnataka, India

Moinak s sarma MD DMSenior Research AssociateDepartment of Pediatric GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknow, Uttar Pradesh, India

Kiran P sathe DCH DNBAssociate Consultant, Department of Pediatrics and Pediatric Nephrology Sir HN Reliance Foundation HospitalMumbai, Maharashtra, India

Veeraraja B sathenahalli MDAssistant ProfessorDepartment of Pediatrics, Jagadguru Jayadeva Murugarajendra Medical CollegeDavanagere, Karnataka, India

Malathi sathiyasekaran MD DCH MNAMS DM

ConsultantDepartment of GastroenterologyKanchi Kamakoti CHILDS Trust Hospital and Sundaram Medical FoundationChennai, Tamil Nadu, India

tulika seth MD ABPAdditional ProfessorDepartment of HematologyAll India Institute of Medical SciencesNew Delhi, India

ira shah MD DCH FCPS DNB DPID Associate Professor Bai Jerbai Wadia Hospital for ChildrenConsultant, Department of Pediatric Infectious Diseases and Pediatric Hepatology, Nanavati HospitalMumbai, Maharashtra, India

Mehul A shah MD DCH MD DABPNConsultant, Department of Pediatric Nephrology, Apollo Health CityHyderabad, Telangana, India

raju c shah MD DPed FIAPProfessor, Department of PediatricsAnkur Institute of Child HealthAhmedabad, Gujarat, India

Jyoti sharma MD DNBConsultant Department of Pediatric NephrologyKing Edward Memorial HospitalPune, Maharashtra, India

Pradeep K sharma MDConsultantSri Balaji Action Medical InstituteNew Delhi, India

sangeetha shenoy MDAssociate ProfessorDepartment of PediatricsMS Ramaiah Medical CollegeBangalore, Karnataka, India

Viraj shingade MS DNBDirectorChildren Orthopedic Care InstitutePravira HospitalNagpur, Maharashtra, India

roli M srivastava DCH PGDAPResearch Officer Department of Obstetrics and GynecologyGanesh Shankar Vidyarthi Memorial Medical CollegeKanpur, Uttar Pradesh, India

Poonam sidana MD Senior Consultant Department of PediatricsMax Super Specialty HospitalNew Delhi, India

sirisharani siddaiahgari MD DNB MRCPCH

Consultant, Department of Pediatric Hematology Oncology Rainbow Children’s HospitalHyderabad, Telangana, India

Aashim singh MBBS Junior ResidentDepartment of DermatologyLady Hardinge Medical College and Associated HospitalsNew Delhi, India

Manav d singh MSAssociate ProfessorDepartment of OphthalmologyPostgraduate Institute of Medical Education and Research and Dr Ram Manohar Lohia HospitalNew Delhi, India

Preeti singh MDAssistant ProfessorDepartment of PediatricsLady Hardinge Medical College and associated HospitalsNew Delhi, India

noopur singhal MDSenior ResidentDepartment of Pediatrics Post Graduate Institute of Medical Education and ResearchDr Ram Manohar Lohia HospitalNew Delhi, India

Pratibha d singhi MDProfessor, Department of Pediatrics Post Graduate Institute of Medical Education and Research Chandigarh, India

Anshu srivastava MD DMAdditional ProfessorDepartment of Pediatric Gastroenterology Sanjay Gandhi Postgraduate Institute of Medical SciencesLucknow, Uttar Pradesh, India

Anurag M srivastava MSConsultant, Rockland Hospital New Delhi, India

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nidhi sugandhi MS MChAssistant ProfessorDepartment of Pediatric SurgeryDr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and ResearchNew Delhi, India

Balasubramanian sundaram MD DCH MAMS FIAP FRCPCH

Senior Consultant, Department of Pediatrics, Kanchi Kamakoti Childs Trust Hospital and The Child’s Trust Medical Research FoundationChennai, Tamil Nadu, India

deepti suri MD DNBAssociate ProfessorDepartment of PediatricsPostgraduate Institute of Medical Education and ResearchChandigarh, India

rhishikesh P thakre DM MD DNB DCH FCPS

ProfessorDepartment of PediatricsMGM College and Hospital Director, Neonatology DivisionNeo Clinic and HospitalAurangabad, Maharashtra, India

s thangavelu MD DCH DNB MRCPSenior Consultant and DirectorDepartment of PediatricsMehta Children’s HospitalsChennai, Tamil Nadu, India

soumya tiwari MDAssistant Professor Department of PediatricsKalawati Saran Children’s hospitalLady Hardinge Medical CollegeNew Delhi, India

Alpana A Utture Dch MD DMAssociate ProfessorDepartment of NeonatologySeth Gordhandas Sunderdas Medical College and King Edward Memorial HospitalMumbai, Maharashtra, India

Jayakumar Vaikundam MD DCH DMSenior Consultant and ChairmanJK Institute of NeurologyMadurai, Tamil Nadu, India

Kiran sK Vaswani MD DCH PGD-AP Dip counselling

ConsultantPULSE Child Care ClinicMumbai, Maharashtra, India

Anoop K Verma MD FIAP FIAMSPediatricianSwapnil Nursing HomeRaipur, Chhattisgarh, India

Madhava Vijayakumar MD DCH DNBAdditional Professor Department of Pediatrics Government Medical College Kozhikode, Kerala, India

M Vijayakumar MD DCH DM FIAPConsultant Department of Pediatric NephrologyMehta Children’s HospitalChennai, Tamil Nadu, India

Vijay Viswanathan DNB DCHConsultant, Sandhi Children’s ClinicJupiter HospitalMGM HospitalDr Yewale’s Multispecialty CentreMumbai, Maharashtra, India

V Viswanathan DCH MRCP PhDSenior Consultant Department of Pediatric NeurologyKanchi Kamakoti Childs Trust HospitalApollo Children’s HospitalChennai, Tamil Nadu, India

sanjay Wazir DMDirector - NICU, Department of PediatricsCloudnine HospitalGurgaon, Haryana, India

Pravesh Yadav MDSenior ResidentDepartment of Dermatology and STDLady Hardinge Medical College and Associated HospitalsNew Delhi, India

M Zulfikar Ahamed MD DMProfessor and HeadDepartment of Pediatric CardiologyGovernment Medical CollegeThiruvananthapuram, Kerala, India

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Publication of any book is a process as laborious as the process of delivering a baby. Maturity (contents and the quality), weight gain (number of pages), and intact survival (final copy) all have to be carefully looked after. More so for a book with 156 chapters running in 19 sections with every chapter having at least one algorithm!

Algorithms in Pediatrics have gone through all these laborious processes and have come out as an exclusive book for pediatricians, giving instant guidelines for treatment, bringing uniformity in management, and training minds for protocolized thinking. With each protocol, the book provides concise, precise, and up-to-date information which shall help standardize care in pediatric practice.

When a practitioner is confronted with a clinical problem, he can rarely turn to a textbook for help. What he needs at that time is not a recounting of a long list of differential diagnosis, but practical guidelines as to how to arrive at a particular diagnosis and how to proceed further.

This book on algorithms intends to enable the pediatrician to recognize many disorders in a simplified manner and give practical suggestions in their management, a learning experience in a structured manner.

To put it in the words of Henry David Thoreau, “Our lives are frittered away by detail; simplify, simplify”.Practicing pediatricians are often faced with clinical problems for which they have been rather inadequately trained

during their medical curriculum. Textbooks published from the medically advanced countries do not focus enough attention on the prevailing problems and circumstances in the developing countries such as India. The algorithms in this book have been formed keeping in mind the situations prevailing in India, especially the constraints under which the clinicians here have to practice. The main emphasis has been to provide clear-cut guidelines as to how to make a diagnosis on clinical grounds with minimal investigations and to choose the most rational therapy.

Although, prepared specifically to meet the needs of practicing doctors or those who intend to practice in near future, even pediatric residents would find the book extremely useful while preparing for their viva voce at the diploma or MD exams. The book covers most of those aspects which are practically never taught in the curriculum but are nevertheless expected to be known by pediatric postgraduates. It will also assist the students, house officers, and clinicians in the evaluation of common pediatric signs and symptoms in clinical practice.

With the help of history, focused examination, and minimum investigations, pediatricians in office practice can reach a working diagnosis and lay down immediate priorities in management.

Pramod Jog MD DNB FIAPProfessor of PediatricsDY Patil Medical CollegePresident, Indian Academy of Pediatrics (IAP), 2016Member, Standing Committee, International Pediatric Association (IPA)Pune, Maharashtra, India

Foreword

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There is rarely a single acceptable approach to any given problem, and not all diagnoses can fit neatly into an algorithm. Even though the protocols cannot be considered all-inclusive, the goal is to facilitate a logical and efficient stepwise approach to reasonable differential diagnoses for the common clinical problems. The algorithmic format provides a rapid and concise stepwise approach to a diagnosis. Moreover, it would train the brain to approach a problem.

The explosion of knowledge in pediatrics is phenomenal and fast. If the medical advances and good clinical practice get coupled with effective advocacy, our increasing knowledge will benefit child care in our country.

I am sure that the algorithms will enhance the capabilities of pediatricians, guiding them towards optimal utilization of available investigative and therapeutic resources.

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Preface

It gives us immense pleasure to present to you the 1st edition of “Algorithms in Pediatrics”. Pediatrics is rapidly advancing with the growth of its subspecialties. At times, it becomes difficult for busy pediatricians, whether in practice, in teaching institutions, or pursuing their postgraduation, to read through lengthy texts of different subspecialties. Keeping this in mind, we thought of bringing forth this concise book on algorithms, which deals with common and practical topics of everyday requirements in different pediatric specialties.

The book has been designed with a practical approach in mind, with an algorithm for each topic, along with a concise text to use the algorithms. The text has been kept simple and easily comprehendible. The book can be consulted rapidly in the emergency room, wards, outpatient departments, or in busy clinics.

The book contains 19 subspecialty sections, with 8–10 chapters in each, a total of 156 chapters. This was an immense work, which could not have been possible without the help and coordination of the section editors. We are very thankful to all the section editors.

A large number of luminaries and experts in the field of pediatrics and its subspecialties have contributed their mind and might in bringing out this book. We are thankful to all these contributors.

We are also thankful to Jaypee Brothers Medical Publishers (P) Ltd. for publishing this book.We are also grateful to our respective spouses for being tolerant and supportive of us in this endeavor.

anand s VasudevNitin K shah

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section 1: Neonatology

section editors: anjali Kulkarni, ashish Mehta

1. neonatal resuscitation 1Rhishikesh P Thakre

2. Apnea 5Naveen Jain

3. respiratory distress in newborn 8Reeta Bora

4. respiratory support in newborns 13Jayashree A Mondkar, Alpana A Utture

5. Persistent Pulmonary Hypertension of the newborn 20Ram G Holla, Ira J Holla

6. Bronchopulmonary dysplasia 23Naveen Bajaj, Ruchi Nanawati

7. Patent ductus Arteriosus 28Kiran P Sathe, Anjali Kulkarni

8. neonatal shock 31 Ranjan K Pejaver, Manisha Halkar

9. Anemia in neonate 34Nandkishor S Kabra

10. Bleeding neonate 39Deepak Chawla

11. neonatal Hyperbilirubinemia (Unconjugated) 43Poonam Sidana, Gaurav Mandhan

12. Hypoglycemia 47Sailesh G Gupta

Contents

13. neonatal seizures 50Sanjay Wazir

14. neonatal sepsis 54Rahul P Bhamkar, Anjali Kulkarni

15. Approach to congenital Heart disease 58Dinesh K Chirla, Preetham K Poddutoor

16. First Golden Hour Management of Preterm 63Naveen Bajaj

17. Perinatal Hypoxia 67Ashish Jain, Veeraraja B Sathenahalli

section 2: adolescence

section editors: MKc Nair, Piyali Bhattacharya

18. teen Pregnancy and contraception 71Prema Raghunathan

19. HEEAdsss Assessment of the Adolescent child 76Piyali Bhattacharya

20. Adolescent Anemia 79Vaishali R Deshmukh

21. Academics and career choices in Adolescents: Approach in the Pediatric office setting 84Ira E Almeida

22. Polycystic ovarian syndrome and Menstrual Problems in Adolescents 87Roli M Srivastava

23. Approach to a case of sexual Abuse in children/Adolescent 94Sushma P Desai

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24. Adolescent depression/suicidal tendency and its Management 101Paula Goel

25. teen Aggression: steps in Management 110Kiran SK Vaswani

section 3: immunization

section editors: amar J chitkara, Jaydeep choudhury

26. immunization in childhood 115Monjori Mitra

27. Missed immunization 121Ritabrata Kundu

28. Animal Bites 123Jaydeep Choudhury

29. Adverse Event Following immunization 127Amar J Chitkara

section 4: Office emergencies

section editors: anand shandilya, rajesh r chokhani

30. Approach to respiratory distress in children 130Narendra R Nanivadekar

31. recognition of child in shock 135Kiran SK Vaswani

32. croup 139Bhavesh M Mithiya

33. Approach to a child with Acute Febrile Encephalopathy 144Surpreet BS Nagi

34. Management of a child with respiratory distress 157Sanjay M Bafna, Kochurani Abraham

35. Hypovolemic shock 162Parmanand GK Andankar

36. Approach to Fever in children 166Rhishikesh P Thakre

37. Approach to Poisoning in children 170Somashekhar M Nimbalkar

38. Approach to Burns in children 175Vibha S Bafna

39. Approach to Envenomation 181Mandar B Patil

section 5: intensive care

section editors: Praveen Khilnani, soonu Udani

40. recognition and Assessment of critically ill child 188Praveen Khilnani

41. septic shock 195Vikram Gagneja, Praveen Khilnani

42. status Epilepticus 201Soonu Udani

43. cardiogenic shock 204Nameet Jerath, Praveen Khilnani

44. Head injury in infants and children 209Bhaskar Saikia, Praveen Khilnani

45. trauma in children 213Soonu Udani

46. Poisoning in children 217Pradeep K Sharma, Praveen Khilnani

47. snakebite Envenomation 223Soonu Udani, Narendra Rathi

48. initial Approach to a comatose child 226Soonu Udani

section 6: infectious diseases

section editors: shyam Kukreja, tanu singhal

49. Fever without Focus in infants Less than 3 Months of Age 228Balasubramanian Sundaram

50. Acute Viral Encephalitis 231Jaydeep Choudhury

51. Acute osteomyelitis 235Baldev S Prajapati, Rajal B Prajapati

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52. Algorithmic Approach to short duration Fever without Focus in older infants and children 241Suhas V Prabhu

53. Fever with rash 243Ritabrata Kundu

54. Approach to Managing new onset Fever in the intensive care Unit 246Tanu Singhal

55. infant Born to Human immunodeficiency Virus infected Mother 250Ira Shah

56. Fever of Unknown origin 253Raju C Shah, Tanu Singhal

section 7: Hematology/Oncology

section editors: Nitin K shah, atK rau

57. A Mass in the Abdomen: the Way to diagnosis 256Gauri Kapoor

58. Approach to a child with Persistent Anemia 260Mamta V Manglani

59. Algorithmic Approach to thrombocytopenia in children 269ATK Rau, Shreedhara Avabratha K

60. Algorithmic Laboratory Approach to a child with Anemia 272Aarathi R Rau

61. recurrent Unusual infections in a child: the Way Forward 277Tulika Seth

62. Approach to Persistent Fever with Hepatosplenomegaly in a child 283Anupam Sachdeva, Vinod Gunasekaran

63. Approach to a Bleeding child 287Nitin K Shah

64. clinic Pathological Approach to coagulation disorder 294Sangeeta S Mudaliar, Bharat Agarwal

65. Algorithmic Approach to Eosinophilia in children 299ATK Rau, Sangeetha Shenoy

section 8: Pulmonology

section editors: Gr sethi, Varinder singh

66. Approach to a child with respiratory distress 303Soumya Tiwari

67. Assessing and Managing a child with stridor 308Dhulika Dhingra, Varinder Singh

68. recurrent Wheezing in infants and Preschool children 312Ankit Parakh, Varinder Singh

69. Managing Acute severe Asthma 317Ankit Parakh, Shalu Gupta, Varinder Singh

70. Management of Bronchiolitis 322Preeti Singh, Varinder Singh

71. Management of Bronchiectasis 327Kana R Jat

section 9: cardiology

section editors: Vikas Kohli, Usha Pratap

72. Management of congestive Heart Failure in infants and children: An Algorithmic Approach 332M Zulfikar Ahamed

73. Approach to a child with chest Pain 338Vikas Kohli, Neeraj Agarwal

74. systemic Hypertension 343Nurul Islam

75. Pediatrician’s Perspective for Postoperative Follow-up of a child 348Vikas Kohli, Mridul Agarwal

section 10: Gastroenterology

section editors: surender K Yachha, anupam sibal

76. chronic diarrhea in children Less than 3 Years of Age 352Moinak S Sarma, Surender K Yachha

77. chronic diarrhea in children More than 3 Years of Age 358Surender K Yachha, Moinak S Sarma

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78. Approach to Upper Gastrointestinal Bleed in children 366Anshu Srivastava

79. Management of Lower Gastrointestinal Bleed 373Malathi Sathiyasekaran

80. Acute Liver Failure 380Vidyut Bhatia, Anupam Sibal, Akshay Kapoor

81. corrosive injury in children 384Barath Jagadisan

82. chronic Abdominal Pain 389Sarah Paul, John Matthai

section 11: Neurology

section editors: Neelu a desai, anaita Udwadia Hegde, Vrajesh Udani

83. Approach to Global developmental delay 392Pratibha D Singhi, Naveen Sankhyan

84. Approach to Psychomotor regression in children 396Anaita Udwadia Hegde, Omkar P Hajirnis

85. Approach to a child with First seizure 404Anju Aggarwal, Anaita Udwadia Hegde

86. Medical Management of Epilepsy 408Veena Kalra, Omkar P Hajirnis

87. Approach to refractory Epilepsies 414Neelu A Desai, Vrajesh Udani

88. Acute Flaccid Paralysis 419V Viswanathan, Padma Balaji

89. Approach to Floppy infant 423Vrajesh Udani, Sarbani S Raha

90. Approach to Ataxia 427Jayakumar Vaikundam

91. Acute Hemiplegia in children: An Algorithm for diagnosis and treatment 435Viraj V Sanghi

92. Approach to a child with spastic Paraplegia 440Arun G Roy, Vinayan KP

93. Acute Febrile Encephalopathy 444Rashmi Kumar

94. Approach to Pediatric Movement disorders 448PA M Kunju, Anoop K Verma

95. Afebrile Encephalopathy: Bedside Approach to diagnosis and Management 458Lokesh Lingappa, Sirisharani Siddaiahgari

section 12: Nephrology

section editors: anand s Vasudev, Pankaj V deshpande

96. Approach to rickets in children 463S Thangavelu, M Vijayakumar

97. disorders of sodium and Potassium 469Sushmita Banerjee

98. Acute Glomerulonephritis 473Noopur Singhal, Abhijeet Saha

99. Approach to Hematuria in children 480Mukta Mantan, Anand S Vasudev

100. Approach to Urinary tract infection 485Pankaj V Deshpande

101. Antenatal renal Anomalies: outcome and Postnatal Management 491Mehul A Shah

102. Acute Kidney injury 497VK Sairam

103. Enuresis 500Jyoti Sharma

104. Approach to renal tubular disorders in children 504Manoj G Matnani

105. nephrotic syndrome in children 510Mukta Mantan, Anand S Vasudev

section 13: endocrinology

section editors: Vaman V Khadilkar, anju Virmani

106. Approach to short stature 514Vaman V Khadilkar, Supriya Phanse Gupte

107. childhood obesity 520Anurag Bajpai

108. An Approach to Hyperglycemia 526Aspi J Irani

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109. Gynecomastia in children 532Raghupathy Palany

110. Precocious Puberty 535Puthezhath SN Menon, Madhava Vijayakumar

111. Persistent Hypoglycemia in newborns and infants 542Ganesh S Jevalikar

112. Approach to a child with disorder of sex development 549Vijaya Sarathi

113. Approach to thyroid disorders in children 556Anju Virmani

114. Endocrine Hypertension in children 560Sudha R Chandrashekhar

section 14: rheumatology

section editor: Priyankar Pal

115. Approach to oligoarthritis 564Vijay Viswanathan

116. Approach to Polyarthritis 568Rashna D Hazarika

117. Fever with Arthritis: An Algorithmic Approach 573Sathish Kumar

118. childhood Vasculitis 578Indira Banerjee, Rakesh Mondal

119. Kawasaki disease 584Anju Gupta

120. Henoch-schönlein Purpura 589Anand P Rao

121. systemic Lupus Erythematosus 592Suma Balan

122. Approach to Juvenile dermatomyositis 598Deepti Suri, Sagar Bhattad

123. Acute osteoarticular infections 601Jasodhara Chaudhuri, Tapas K Sabui

124. Eye involvement: Beyond infections 605Manjari Agarwal

section 15: Pediatric surgery

section editors: anurag Krishna, rasik s shah

125. Empyema thoracis: Management Algorithm 609Rasik S Shah, Suyodhan A Reddy

126. Evaluation of Acute Abdominal Pain in children 615Ketan P Parikh

127. Management of Undescended testis: cryptorchidism 622Rasik S Shah, Suyodhan A Reddy, Nachiket M Joshi

128. Acute scrotum 629Mohan K Abraham

129. Per-rectal Bleeding 632Dasmit S Khokar

130. inguinal Hernia 637Satish K Aggarwal, Nitin Pant

131. Antenatal Hydronephrosis 642Anurag Krishna

132. Management of Vesicoureteric reflux 646Minu Bajpai, Aparajita Mitra, Manisha Jana, Rakesh Kumar, Chandra S Bal

133. intussusception 651Gautam S Agarwal, Anurag Krishna

134. neonatal Jaundice: surgical Perspective 655Nidhi Sugandhi, Veereshwar Bhatnagar

section 16: dermatology

section editor: Vibhu Mendiratta

135. Atopic dermatitis 661Vibhu Mendiratta, Nikita, Sarita Sanke

136. Approach to a child with Hypopigmented Macules 664Vibhu Mendiratta, Pravesh Yadav

137. Pediatric Acne 667Vibhu Mendiratta, Niti Gaur, Aashim Singh

138. Approach to congenital Melanocytic nevus 670Vibhu Mendiratta, Pravesh Yadav

139. seborrheic dermatitis 672Vibhu Mendiratta, Nikita, Sarita Sanke

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section 17: Ophthalmology

section editor: shashi Vashisht

140. Approach to red Eye in children 675Suma Ganesh, Priyanka Arora

141. compensatory Head Posture 680Manav D Singh

142. Pediatric Epiphora 687Shashi Vashisht

143. deviation of Eyes 691Taru Dewan, Harshika Chawla

144. decreased Vision in children 696Shikha Jain

section 18: ear, Nose, and throat

section editor: Girish raheja

145. Hearing screening and Management in newborn 699Atul Ahuja

146. Hoarseness in Pediatric Age Group 704Kumud K Handa, Aru C Handa, Dilip Samal

147. otitis Media with Effusion 709Anurag M Srivastava, Anil K Monga, Uday Monga

148. Pediatric sinusitis 717Devinder Rai

149. stridor in children 723Arvind S Bais

150. Upper Airway obstruction and sleep related Breathing disorders 727Girish Raheja

section 19: Orthopedics

section editors: taral V Nagda, rujuta Mehta

151. septic Arthritis 733Viraj Shingade, Mandar Agashe

152. Angular and rotational deformities in children 739Taral V Nagda, Venkatadass Krishnamoorthy

153. Approach to a child with a Limp 746Sandeep A Patwardhan, Anirban Chatterjee, Arjun A Dhawale

154. Pulled Elbow, Growing Pains, and Flatfoot 751Premal Naik, Hitesh B Chauhan

155. clubfoot treatment: current concepts 755Rujuta Mehta, Alaric J Aroojis

156. developmental dysplasia of the Hip 761Jayanth S Sampath, Rujuta Mehta

Index 767

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Plate 4

Fig. 19: Smear showing a bizarre picture with normoblasts and target cells in thalassemia major (Chapter 58)

Fig. 1: Upper gastrointestinal endoscopy showing large esophageal varices (Chapter 78)

Fig. 2: Upper gastrointestinal endoscopy showing gastric varices with red color signs on retroversion (Chapter 78)

Fig. 3: Upper gastrointestinal endoscopy showing duodenal ulcer without signs of active bleeding (Chapter 78)

Fig. 1: Bluish black hemangiomas on the sole and hemangiomas on colonoscopy (blue rubber bleb nevus syndrome) (Chapter 79)

Fig. 2: Oral buccal mucosal pigmentation and colonic polyps (Peutz Jegher’s syndrome) (Chapter 79)

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DEFINITIONLower gastrointestinal bleed (LGIB) indicates bleeding from sites distal to the ligament of Trietz presenting as bleeding per rectum (PR).

The introduction of capsule endoscopy and double balloon enteroscopy in the diagnostic armamentarium of LGIB has given rise to a new term midgastrointestinal bleeding (MGIB) for a bleed occurring anywhere distal to the ampulla of Vater and up to the ileocecal valve. In this article, both small bowel bleed (MGIB) and colonic bleed have been included in the discussion.

TYPES OF BLEEDLower gastrointestinal bleed may be overt or occult. Overt bleeding can be acute massive or chronic intermittent and can present as hematochezia (passage of frank blood per rectum), melena or streaks of blood. Occult bleeding is not clinically apparent but becomes manifest by laboratory evidence of iron deficiency or chemical evidence of blood in the stool. Obscure gastrointestinal bleeding refers to a bleed where the bleeding site is not obvious even after evaluation by upper gastrointestinal endoscopy, an ileocolonoscopy, or a contrast radiological study of the small intestine.

INCIDENCELower gastrointestinal bleeding in infants and children is common in clinical practice yet its epidemiology has not been well studied. In an emergency department in Boston, United States, rectal bleeding was the prime complaint in 0.3% of more than 40,000 patients with life-threatening bleed occurring in 4.2%, three of whom had ileocolic intussusception and one Meckel’s diverticulum.

ETIOLOGYThe common causes of LGIB in children depend on the age of presentation. In this article, the neonatal causes of LGIB have not been included. The causes of LGIB are:1. Gastrointestinal (Table 1)2. Hematological: bleeding disorders, coagulation defects,

DIC, thrombocytopenia (dengue, idiopathic thrombo-cytopenia purpura)

3. Vasculitic disorders: Henoch‒Schönlein purpura4. Connective tissue disorders: Ehlers-Danlos syndrome and

Cutis laxa5. Factitious: various coloring agents, jelly, beetroot, and

drugs such as phenolphthalein or rifampicin can color the stool.

TaBLE 1: Gastrointestinal causes

1 month to 2 years 2 to 12 years 12–18 years

Anal fissure Anal fissure Anal fissureCow’s milk protein allergy Juvenile polyp Infection colitisInfectious/Allergic colitis Infectious colitis Inflammatory bowel diseaseLymphonodular hyperplasia Inflammatory bowel disease Solitary rectal ulcerMeckel’s diverticulum Solitary rectal ulcer Colonic polypIntussusception Intussusception HemorrhoidsVolvulus Intestinal duplication Intestinal duplicationSegmental enteritis Segmental enteritis Segmental enteritisVascular malformations Vascular malformations Vascular malformations

Malathi Sathiyasekaran

Management of Lower Gastrointestinal Bleed

79ChaPTEr

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SECTION 10: Gastroenterology

MaNaGEMENT OF LOwEr GaSTrOINTESTINaL BLEED

Clinical EvaluationA focused yet detailed history and physical examination are essential in the evaluation of all children with LGIB.

historyA meticulous history including details such as whether bleed is major or minor, chronic recurrent or acute massive, treatment, and associated symptoms. Details of the bleed such as duration, number of episodes, frequency, volume, color, presence of clots, mucus, frank bleed, or mixed with feces should be obtained. History will help in establishing the site and probable etiology.Site of bleed: 10% of UGIB may present with bleeding PR. Hematemesis is suggestive of UGIB. Similarly, melena is more often seen in UGIB, whereas hematochezia is usually from small bowel or colon. Specks or streaks of bright red blood indicate bleed from anorectal region.Etiology: acute massive bleed may be due to Meckel’s diverticulum, intestinal duplication, or arteriovenous malformation. Eliciting certain associated symptoms in the history help in determining the etiology of LGIB:• Crampy abdominal pain and frequent loose stools mixed

with mucus and blood suggest an infectious, inflammatory, or ischemic pathology

• Painless bleeding is more typical of a colonic polyp, Meckel’s diverticulum, ulcerated duplication, or vascular malformation

• Painful defecation with streaks of blood suggests anal fissure

• Colicky abdominal pain, vomiting, red currant jelly stool, and mass abdomen are suggestive of intussusception

• Constipation, mucorrhea, small rectal bleed, with or without digital evacuation, and rectal prolapse may suggest solitary rectal ulcer syndrome (SRUS)

• Recent antibiotic administration followed by passage of blood and mucus in stools would indicate antibiotic associated colitis or pseudomembranous colitis

• An infant with stools mixed with blood following introduction of bovine milk protein one should suspect Cow’s milk protein allergy

• An infant of normal weight on breast milk with blood in the stool may have benign allergic proctocolitis due to transfer of allergen through breast milk

• Passage of large volume, maroon or bright red blood requiring blood transfusions suspect Meckel’s diverticulum, intestinal duplication, or arteriovenous malformation

• Mass prolapsing per rectum with bleeding could be due to a prolapsing polyp, prolapse rectum, or an intussusceptum vascular. A polyp is globular and prolapses soon after defecation, a prolapse is circumferential with a central lumen whereas in intussusception severe pain is a characteristic feature

• A family history of bleeding PR requiring surgical intervention polyposis coli may be a possibility

• Failure to thrive, recurrent infections with bleeding PR may point to immune deficiencies either congenital or human immunodeficiency virus related

• History of ingestion of beet or coloring agents suggests factitious bleed

• History of recurrent petechiae, ecchymosis, or epistaxis in addition to bleeding PR may suggest a hematological disorder

• Abdominal pain, diarrhea, loss of weight, pedal edema, and fever suggests inflammatory bowel disease (IBD)

• History of abdominal pain, bleeding PR with rash on legs and gluteal region suggests Henoch‒Schönlein purpura

• History of fever, rash, features of third spacing, and bleeding PR consider dengue fever

• Cutaneous hemangioma and bleeding PR suspect blue rubber bleb nevus syndrome (Fig. 1)

• Family history of bleeding PR, buccal pigmentation consider Peutz Jegher’s syndrome (Fig. 2)

• Telengiectasia on fingers and lips with bleeding PR consider hereditary hemorrhagic telangiectasia

Fig. 1: Bluish black hemangiomas on the sole and hemangiomas on colonoscopy (blue rubber bleb nevus syndrome) (For color version, see Plate 4)

Fig. 2: Oral buccal mucosal pigmentation and colonic polyps (Peutz Jegher’s syndrome) (For color version, see Plate 4)

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375

Fig. 3: Infant with dengue and thrombocytopenia with ecchymosis both ankles (For color version, see Plate 5)

Fig. 4: Palpable Henoch-Schonlein purpura (For color version, see Plate 5)

Stool examination: a simple macroscopic examination of the stool is essential before considering sophisticated investigations.

Microscopic examination: if the stools show more than 10 pus cells/HPF it may indicate an invasive form of colitis. Presence of numerous eosinophils would suggest an allergic colitis or cow’s milk protein allergy. The presence of trophozoites with hemophagocytosis would be diagnostic of Entamoeba histolytica infection. If the clinical setting is suggestive of infectious colitis then stool culture for Shigella, Salmonella, and Campylobacter jejuni may be helpful. Occult bleeding is identified by testing stool for occult blood.

Radiology: plain X-ray abdomen is done when there is pain, bilious vomiting, or features of intermittent intestinal obstruction. Ultrasonography can detect bowel wall thickening pseudokidney appearance or identify characteristic features of intussusception such as target sign (Fig. 5). Air contrast or saline contrast enema helps not only to confirm but also treat ileocolonic intussusception. Computerized tomography or magnetic resonance angiography is generally reserved for evaluation of mass lesions or complex vascular anomalies. Endosonography helps in the visualization of submucosal lesions and arteriovenous malformations.

Radionuclide studies: scintigraphy is useful in the evaluation of children with obscure but active LGI bleed of at least 0.1 mL/minute. In young children with acute massive bleed if Meckel’s diverticulum or duplication cyst is suspected radionuclide studies may be done even prior to endoscopy. Radionuclide study using technetium-99m (Tc99m) per technetate helps to identify ectopic gastric mucosa within a Meckel’s diverticulum or a duplication cyst with a sensitivity of 85%, specificity 95%. Technetium-labeled red blood cells identifies arteriovenous malformations and bleeding ulcers.

Endoscopy: when the bleed is chronic and intermittent ileocolonoscopy is preferred as the first line of investigation. Upper gastrointestinal endoscopy should always be done along with ileocolonoscopy since 10% of upper gastrointestinal bleed can present as bleeding per rectum.

ExaminationGeneral: in children with acute lower gastrointestinal bleed whether major or minor a complete examination including vital signs is necessary.

Skin: examination of the skin for petechia, ecchymosis, palpable purpura (Figs 3 and 4) and hemangiomas, buccal pigmentation, and café au lait spots to exclude familial syndromes.

Abdomen: Splenomegaly may indicate portal hypertension. Right upper quadrant mass may indicate intussusception. Distended abdomen with dilated bowel loops suggests intestinal obstruction, volvulus, gangrene, or segmental enteritis.

Perianal examination: the presence of skin tags, perianal fistula or fissure may be markers of IBD.

InvestigationsLaboratory studies: basic investigations such as hemoglobin, total and differential white blood cell count, platelet, bleeding time, clotting time, and prothrombin time are included in the investigative panel. Refractory iron deficiency anemia is an important manifestation of occult gastrointestinal bleed and should be evaluated diligently.

Fig. 5: Abdominal ultrasound showing target sign “intussusception”

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Ileocolonoscopy: early colonoscopy helps both in diagnosis and therapy of mucosal lesions of the colon. The overall yield ranges from 69 to 80%. Bowel preparation is safely achieved in children using a standard oral polyethylene-glycol electrolyte solution. Ileocolonoscopy helps both in the diagnosis and therapy of LGIB. The majority of mucosal lesions, such as allergic colitis, polyps, solitary rectal ulcer, IBD, vascular malformations, rectal varices, portal colopathy (Figs 6–12), can be diagnosed. Biopsy of the mucosal lesions will help in confirming the etiology.

additional ProceduresThe above investigations will suffice to identify the source of bleeding in the majority of children with LGIB. However, in a small percentage (3–5%), the source will remain obscure necessitating small bowel examination, either with triple vessel arteriography, small bowel enema, magnetic resonance enteroclysis, enteroscopy, or intraoperative enteroscopy.

Fig. 6: Solitary rectal ulcer (For color version, see Plate 5)

Fig. 7: Rectal varices (For color version, see Plate 5)

Fig. 8: Colonic polyp (For color version, see Plate 5)

Fig. 10: Irregular colonic ulcer: Crohn’s disease (For color version, see Plate 6)

Fig. 9: Ano fissure (For color version, see Plate 5)

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Impaction of the capsule may occur if there is an underlying stricture

Intraoperative EnteroscopyIn this procedure, both surgeon and endoscopist work as a team in the evaluation of a child with LGIB. A pediatric colonoscope or enteroscope can be negotiated through an operative enterotomy and the small bowel visualized. It helps in detecting the majority more than 85% of obscure small bowel bleeding lesions. The surgeon guides the intestine over the scope and examines the outer serosa by palpation and transillumination while the endoscopist examines the inner mucosa.

Diagnostic Laparoscopy/LaparotomyIn children with recurrent gastrointestinal bleed, and if investigations are futile, it may be worthwhile performing a diagnostic laparoscopy to identify lesions such as enteric duplication cyst.

ManagementThe management of lower GI bleed includes prompt resusci-tative measures and treatment of the specific condition by five distinct modalities such as diet modification, medications, endotherapy, radiological intervention, and surgery.

Diet• Cow’s-milk protein allergy (CMPA): avoidance of bovine

milk protein and milk products till the age of 9 months to 1 year is recommended for all infants diagnosed as having significant CMPA. Majority will be able to tolerate cow’s milk protein by the age of 3–5 years

• Fissure in ano and solitary rectal ulcer syndrome (SRUS): introduction of fruits and vegetables to increase bulk and fiber will benefit children with LGIB due to fissure in ano or SRUS.

Medications• Bacillary dysentery: in India, the recommendation is to

consider infectious colitis as Shigella colitis and treat with oral cefixime 10 mg/kg/day for 7 days if child is ambulant and with intravenous ceftriaxone 100 mg/kg for those hospitalized

• Amoebic colitis: routine antiamebic medication should not be prescribed for children with acute colitis. Metronidazole 10 mg/kg/day thrice a day for 5 days is given only if trophozoite with hemophagocytosis suggestive of Entamoeba histolytica is identified or in spite of two antibiotics which are known to be sensitive for Shigella in that region have been administered and the child has persistence of symptoms

• Ulcer bleeds: proton pump inhibitors like omeprazole at a dose of 0.7 to 1 mg/kg/day or H2 blockers, such as ranitidine at a dose of 4–6 mg/kg/day, can be administered or orally if the bleed is secondary to duodenal ulcer, gastric ulcer, or nonsteroidal anti-inflammatory drugs induced gastrointestinal injury. Proton pump inhibitors score over

Fig. 12: Nodular lymphoid hyperplasia cow’s-milk protein allergy (For color version, see Plate 6)

Fig. 11: Severe ulcerative colitis (For color version, see Plate 6)

Triple arteriographyThis is rarely necessary in children with LGIB. It is, however, useful in obscure small bowel bleed if there is active bleeding of at least 0.5 mL/minute. The advantage of arteriography is that it helps both in localization and embolization of the lesion.

Double Balloon EnteroscopyThis procedure helps in visualizing the entire small bowel up to the ileocecal valve. It is not regularly used in pediatrics but may be warranted in older children and adolescents with obscure LGIB.

Capsule EndoscopyChildren more than 5 years of age can swallow the capsule but in younger children, it can be introduced endoscopically. Capsule endoscopy is an excellent modality for identifying obscure gastrointestinal bleed. The detection rate is higher (87–92%) if the procedure is done during active bleed.

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ranitidine in controlling ulcer bleeds and is recommended at a dose of 1 mg/kg and given slow intravenous followed by infusion

• Coagulopathy: injection of vitamin K (1 mg/year of age, maximum 10 mg) intravenous/intramuscular is given when the bleed occurs in individuals with colopathy and hepatocellular dysfunction. Fresh frozen plasma (FFP) may be necessary in children with prolonged international normalized ratio not responding to injection of vitamin K

• Thrombocytopenia and coagulopathy: in children with LGIB secondary to thrombocytopenia as in dengue fever or dengue shock syndrome platelet transfusion, FFP and rarely recombinant factor V may be required

• Variceal bleed: the role of octreotide and somatostatin is well established in acute variceal bleed. When the bleed is nonvariceal, somatostatin and its analog octreotide (1–2 μg/kg bolus followed by 1 μg/kg/hour continuous intravenous or 1 μg/kg every 8–12 hours subcutaneously for 24–48 hours) may reduce the risk of continued or recurrent bleeding. These vasoactives act by reducing the splanchnic flow and may help in tiding over the crisis till active intervention is available

• Inflammatory bowel disease: in IBD, the bleeding stops once the activity of the disease is controlled. Inflammatory bowel disease is managed according to the severity of disease. Five amino salicylic acid 40–50 mg/kg/day is initiated in children with mild ulcerative colitis (UC) and mild Crohn’s disease (CD). Steroids at a dose of 1 mg/kg/day is given for induction of remission and tapered over a period of 12 weeks in moderate UC or CD. Immunomodulators such as azathioprine 6 mercaptopurine are excellent steroid sparing agents and used in the phase of maintenance

• Anal fissure can be managed with stool softeners and high fiber diet

• Solitary rectal ulcer syndrome is managed by encouraging the child to increase fiber in the diet and thus avoiding constipation and straining during defecation. The child is trained to acquire a proper and regular bowel habit. In some situations, several sittings of biofeed back therapy may be required. Various modalities of topical therapy have been tried such as 5 amino salicylic acid suppository and sucralfate enema. When the bleed is severe and not responding to dietary modifications Argon plasma coagulation and surgery may be recommended.

Endotherapy• If SRUS does not respond to medications, endoscopic

laserization with argon plasma can be attempted• Colonic polyps are managed by endoscopic polypectomy

Interventional radiology• Intussusception in infants less than 2 years can be reduced

either with air or saline enema• When the bleed occurs due to an arteriovascular

malformation or a bleeding, aneurysm embolization using coils is an excellent method to arrest the bleed.

Surgery• Children with familial polyposis coli are advised total

colectomy to prevent malignancy• Intussusception which has not been reduced by pneumatic

reduction should be tackled surgically• Meckel’s diverticulum, volvulus, and duplication are all

managed surgically.

aLGOrIThM 1

Management of lower gastrointestinal bleeding after stabilization of child

*Radionuclide studies RBC tagged/pertechnetate.

LGIB, lower gastrointestinal bleeding; RNS, radio nuclide studies; UGIE, upper gastrointestinal endocospy.

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CONCLUSIONLower gastrointestinal bleed presenting as bleeding per rectum is a common problem in children and may be due to several causes. The bleed may be very insignificant or sinister. A careful detailed history and clinical examination will help in diagnosis. Since acute massive bleed in young children is usually due to Meckel’s diverticulum or duplication cysts, radio nuclide scan using Tc99m pertechnetate may be done as a precedent to ileocolonoscopy. The given algorithm 1 for LGIB should be modified according to the age of the child, clinical presentation, and feasibility of investigation.

• Lower gastrointestinal bleed may be insignificant or sinister in presentation

• Detailed history and simple macroscopic examination of stool is the most important tool in evaluation

• Meckel’s scan should be included in the initial diagnostic workup of infants with acute massive bleed

• Ileocolonoscopy is a safe procedure for both diagnosis and therapy of lower gastrointestinal bleeding.

Clinical Pearls

KEY POINTS

)) Lower gastrointestinal (GI) bleeding may be due to GI and non-GI causes)) Lower gastrointestinal bleeding (LGIB) may be chronic intermittent or acute massive)) Essential to evaluate and identify the etiology)) In acute massive GI bleed, radio nuclide scan may be done prior to endoscopy)) Ileocolonoscopy should be included in the protocol)) Surgery is indicated in some select conditions of LGIB.

SUGGESTED rEaDINGS

1. Abraldes JG, Bosch K. Somatostatin and analogues in portal hypertension. Hepatology. 2002;35:1305-12.

2. Arguelles-Arias F, Caunedo A, Romero J, Sánchez A, Rodríguez-Téllez M, Pellicer FJ, et al. The value of capsule endoscopy in pediatric patients with a suspicion of Crohn’s disease. Endoscopy. 2004;36:869-73.

3. Chaudhary V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998;64:723-8.

4. Ell C, May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy. 2006;38(1):73-5.

5. Fox VL. Gastrointestinal bleeding in infancy and childhood. Gastroenterol. Clin N Amer. 2000;29:36-64.

6. Khurana AK, Saraya A, Jain N, Chandra M, Kulshreshta R. Profile of lower gastrointestinal bleeding in children from a tropical country. Tropical Gastroenterol. 1998;19:70-1.

7. Lacroix J, Nadeau D, Laberge S, Gauthier M, Lapierre G, Farrell CA. Frequency of upper gastrointestinal bleeding in a pediatric intensive care unit. Crit Care Med. 1992;20:35-42.

8. Leung Alexander KC, Wong AL. Lower gastrointestinal bleeding in children. Pediatr Emeg Care. 2002:18:319-23.

9. Pandey S, Srivastava A, Lal R, Yachha SK, Poddar U. Enteric duplication cysts in children: A target in algorithm for evaluation of lower gastrointestinal bleeding. Indian J Gastroenterol. 2014;33:285-8.

10. Poddar U, Thapa BR, Vaiphei K, Singh K. Colonic polyps: experience of 236 children. Am J Gastroenterol. 1998;93:619-22.

11. Siafakas C, Fox VL, Nurko S. Use of octreotide for the treatment of severe gastrointestinal bleeding in children. J Pediatr Gastroentrol Nutr. 1998;26:356-9.

12. Strate LL. Lower GI bleeding:epidemiology and diagnosis. Gastroenterol Clin N Am. 2005:34:643-64.

13. Vinton NE. Gastrointestinal bleeding in infancy and childhood. Gastroent Clin N Amer. 1994;93-188.

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