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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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Contributors
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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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Algorithms in Pediatrics
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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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.
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