Indications and Timing of Intervention for Common Congenital Heart Diseases (ASD)

Indications and Timing of Intervention for Common Congenital Heart Diseases

Atrial Septal Defect (ASD)

Diagnostic work-up:

Physical examination, ECG, X-ray chest, echocardiography, and cardiac catheterization (may need in select cases).

Types of Atrial septal defect:

Ostium secundum (~75%);

Ostium primum (15%-20%);

Sinus venosus (5%-10%); and

Coronary sinus (<1%). 

Patent foramen ovale:

Small defect in fossa ovalis region with a flap with no evidence of right heart volume overload. Diagnosed on echocardiography, is a normal finding in newborns. 

Indication for closure:

ASD with left-to-right shunt associated with evidence of right ventricular volume overload without evidence of irreversible pulmonary vascular disease.

Indications for ASD closure remain the same irrespective of the method of closure.

Contraindications for closure:

Severe pulmonary arterial hypertension or irreversible pulmonary vascular disease. 

Ideal Age of Closure Asymptomatic child:

2-4 years. For sinus venosus defect surgery may be delayed to 4-5 years.

Symptomatic ASD: Rarely seen in infants. Present with congestive heart failure, pulmonary arterial hypertension. Early closure is recommended after ruling out associated lesions such as left ventricular inflow obstruction, aortopulmonary window, total anomalous pulmonary venous drainage, etc.

If presenting beyond ideal age: Elective closure irrespective of age as long as there is left-to-right shunt with right heart volume overload and pulmonary vascular resistance is within operable range.

Method of Closure:

Surgical: Established mode.

Device: For secundum ASDs with adequate rims and weight of child >15kg.

Recommendations for Follow-up:

Follow-up after surgical closure: Clinical and echo in the first year only. No further follow-up required if no residual disease, no pulmonary hypertension or arrhythmia.

Patient/guardians should be explained about reporting to hospital in case of any cardiac symptoms, or symptoms suggestive of arrhythmias.

Follow-up after device closure:

(a) Anti-platelet agents for total duration of 6 months

(b) Echocardiography: - At discharge, 1 month, 6 months, 1 year, then every 3-5 years.

Infective endocarditis prophylaxis: It is recommended for 6 months after device or surgical closure. However, all patients are advised to maintain good oro-dental hygiene after this period also.

IRON DEFICIENCY ANEMIA: WHAT A GLOBAL PROBLEM? CLICK BELOW TO LEARN ABOVE IRON DEFICIENCY ANEMIA.

Question#01

As iron becomes depleted from the body, what is the progression at which laboratory tests change?

For answer, click at 
https://pediatricmcqsseqsbank.blogspot.com/2020/04/answer-to-question-01.html



Question#02
How is the RDW useful for distinguishing causes of microcytic anemia?


For answer, click at 
https://pediatricmcqsseqsbank.blogspot.com/2020/04/answer-to-question-02.html



Question#03
What is the Mentzer index?

For answer, click at 
https://pediatricmcqsseqsbank.blogspot.com/2020/04/answer-to-question-03.html



Question#04
In a child with suspected iron-deficiency anemia, is a therapeutic trial with iron an acceptable diagnostic approach?


For answer, click at 
https://pediatricmcqsseqsbank.blogspot.com/2020/04/answer-to-question-04.html


Question#05
After iron therapy is initiated, how early can a response be detected?

For answer, click at 
https://pediatricmcqsseqsbank.blogspot.com/2020/04/answer-to-question-05.html

PEDIATRIC EPILEPSY: General therapeutic aspects

PEDIATRIC EPILEPSY: General therapeutic aspects

If the diagnosis of epilepsy can be made securely on the basis of the clinical findings and further testing, an appropriate course of therapy must be decided upon. Any underlying cause of symptomatic epilepsy should be treated (causally directed treatment); moreover, the predisposition to seizures can be treated symptomatically with one or a combination of drugs (ant iepileptic drugs, AEDs). Not every epileptic seizure implies a need for treatment.

In many patients with a first seizure, it may be best to wait and see whether the event will repeat itself, as long as this presents no special danger and the parents agree. The decision whether to treat with drugs must always be taken on an individual basis, with due consideration of the patient’s personality, life situation, occupation, need to drive a car, and so forth (in older children)

The following situations are generally considered indications for treating epilepsy with drugs:

§   Two or more unprovoked epileptic seizures.

§   One or more unprovoked epileptic seizures in the setting of a known disease of the brain (epileptogenic structural lesion, encephalitis, cerebral hemorrhage, tumor, etc.).

§   Epilepsy-typical potentials on EEG.

§   Initial status epilepticus.

The general principles of the treatment of epilepsy are as follows:

§   Thorough parents education.

§   Avoidance of precipitating factors (regular sleep habits, no illicit drugs, caution with prescription drugs, and avoidance of strobe lights).

§   Treatment of the underlying disease, if any (e.g., resection of a meningioma)

§   If pharmacotherapy is indicated: choice of a suitable drug for the particular seizure type (see table).

§   Gradual increase of the dose till seizure control is achieved or intolerable side effects arise. Beware of treatment failure through under-dosing: the side effect threshold varies greatly from patient to patient and must be crossed, or nearly so, before a drug can be declared ineffective.

§   Meticulous follow-up for possible side effects, with especially close observation in the initial phase of treatment.

§   Checking for compliance, for example, with serum levels, if the drug seems to be ineffective.

§   If treatment with the first drug tried is truly ineffective despite maximal dosing and adequate compliance, switch to another drug of first choice, in gradual and overlapping fashion.

§   Combination therapy only if monotherapy fails.

§   Determination of serum levels when:

-         Poor compliance is suspected.

-         Toxic drug effects are suspected.

-         Drug interactions are suspected, particularly those involving enzyme induction.

-         An already high dose is to be raised even further.

§   Rules of thumb for the discontinuation of AEDs: the patient should be free of seizures for at least 2 years; the EEG should be free of potentials that are typical for epilepsy; traditionally, the drug is slowly tapered to o over several months (although the need for this has not been demonstrated); the patient and family must be explicitly told that seizures may recur during or after the tapering phase.

§   If a patient with focal seizures has not become seizure-free with two AEDs, the possibility of epilepsy surgery should be considered early.

§  In patients with treatment-resistant focal or generalized seizures, the seizure frequency can be reduced with vagus nerve stimulation.

Antiepileptic drugs and their indications, by type of epilepsy. The drugs are listed in alphabetic order 

Choice	Focal seizures	Generalized seizures			Special epilepsy syndromes of childhood
	Focal seizures with or without secondary generalization	Primary generalized tonic–clonic seizures	Absences seizures	Myoclonic seizures	West syndrome (salaam spasms)	Lennox–Gastaut syndrome (myoclonic– astatic petit mal)	Rolandic epilepsy (benign epilepsy in childhood and adolescence with central spikes on EEG)
1st Choice	Carbamazepine Lamotrigine Levetiracetam Oxcarbazepine Topiramate Valproate	Lamotrigine Levetiracetam Topiramate Valproate	Valproate	Lamotrigine Valproate	Vigabatrin Valproate	Valproate	Carbamazepine Sultiame
2nd Choice	Clonazepam Gabapentin Phenobarbital Phenytoin Primidone Tiagabine Vigabatrin	Phenobarbital Primidone	Clonazepam Lamotrigine Topiramate	Clonazepam	ACTH Clonazepam Levetiracetam Primidone	ACTH Carbamazepine Clobazam Felbamate Phenytoin	Valproate Phenytoin
3rd Choice Combinations	Lamotrigine + Valproate or Lamotrigine +levetiracetam	Valproate + clonazepine or Valproate + topiramate	Valproate + ethosuximide or Lamotrigine +topiramate	Valproate + clonazepam	Lamotrigine + levetiracetam	Valproate + lamotrigine	?

Abbreviations: ACTH, adrenocorticotropic hormone

Has Antibiotic Pretreatment effect on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis? Interesting articles with 2019 updates

Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis

Partially treated meningitis

Many children receive antibiotics before definitive diagnosis is made. As a rule, a few doses of oral antimicrobial agents, or even a single injection of an antibiotic, do not significantly alter CSF findings, including bacterial cultures, especially in patients with H influenzae type b (Hib) disease. Oral antibiotics have never convincingly been shown to render patients with bacterial meningitis CSF culture–negative.

CSF cultures may become sterile rapidly if the pathogen was a pneumococcus or meningococcus, though cellular changes, an increase in protein, and low glucose levels persist. In such cases, CSF, blood, and urine should be tested for bacterial antigens; however, the presence of a negative antigen result does not entirely rule out a bacterial source.

In cases where antibiotic administration leads to CSF sterilization, polymerase chain reaction (PCR) testing may have a role to play in identifying the pathogen. PCR testing is able to identify the pathogen quickly and accurately and does not require a large number of organisms; however, it does require further validation in this setting.

Nigrovic et al found that Gram stain results (WBC count and absolute neutrophil count) in CSF were not affected by pretreatment with antibiotics; however, the rates of positive CSF culture and blood culture were lower with antibiotic pretreatment. After pretreatment with antibiotics for 12 hours or longer, the patients had higher CSF glucose levels and lower CSF protein levels.

For details click at

https://emedicine.medscape.com/article/961497-workup#c9

For study conducted by Nigrovic et at, login at

https://reference.medscape.com/medline/abstract/18829794

PEDIATRICS UP-DATES: Indication for Tonsillectomy (+/– Adenoidectomy)

Indication for Tonsillectomy (+/– Adenoidectomy):

Absolute Indications

• Moderate to severe obstructive sleep apnea

• Suspicions of tonsillar malignancy, including posttransplant lymphoid proliferative disorder (PTLD)

Relative Indications

• Mild obstructive sleep apnea

• Recurrent tonsillitis—must meet criteria:

–– Frequency:

◦◦ Seven or more episodes in 1 year

◦◦ Five or more episodes per year for 2 years

◦◦ Three or more episodes per year for 3 years

• Associated with one or more of the following:

–– Temperature > 38.3 ° C (101 °F)

–– Cervical lymphadenopathy

–– Tonsillar exudate

–– Positive test for GABHS

• Chronic tonsillitis unresponsive to antimicrobial therapy

•  Severe halitosis

•  Peritonsillar Abscess (greater than one episode)

• PFAPA syndrome (periodic fever, aphthous ulcers, pharyngitis, cervical adenitis)

• PANS/PANDAS syndrome: a controversial indication (pediatric acute-onset neuropsychiatric syndrome/pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)

Indication for Adenoidectomy Alone

• Moderate to severe nasal obstruction with persistent symptoms

• Refractory chronic sinusitis

• Recurrent acute otitis media or otitis media with effusion in a child who had prior tympanostomy tubes that have now extruded (e.g., repeat surgery when indicated would consist of adenoidectomy plus myringotomy ± insertion of ventilation tube) and is over 4 years of age

PEDIATRICS UP-DATES

PEDIATRICS UP-DATES

Q#01

Which patients with UTIs are at higher risk for having an abnormality? Mention only 5.

Q#02

After what period can AEDs be safely discontinued?

Q#03

When the decision is made to discontinue AEDs, should the tapering period be long or short?

Q#04

What are the two most common pediatric vasculitides?

Q#05

Which laboratory tests are useful for monitoring the effectiveness of therapy in patients with SLE?