Child and Chest Health Care Delhi NCR

Cardiac murmur on routine clinical examination of children is not uncommon.

It affects approximately 65%-80% children in school going age.

It is the most disturbing clinical finding revealed to parents.

Clinicians are compelled to confirm its pathological nature by referring the child to cardiologists and getting a costly test done in the form of echocardiography.

Moreover,this echocardiography test is not available everywhere.

According to a study by Dr.Bruno Lefort and colleagues from Gatien de Clocheville Children hospital,Tours University hospital centre France, a cardiac murmur in children aged 2-18 years auscultated in supine position with no other cardiac sign and symptom and no family history of heart disease is almost always nonpathological, if the murmur vanishes when auscultated making the child in standing position.

In their study of 100 children with cardiac murmur in supine position that disappeard on standing position ,only 2 children were proved to have pathological murmur.

In the France study during 2014-2015,194 children referred consequitevely to cardiologist were first auscultated in supine position,then on  standing position and then echocardiography were done.The average age of the children was 6-7 years and most of them were boys.

30(15%) children were indentified as having pathological murmur by echocardiography in this study.

Murmur persisted on  standing position in 93% and decreased in intensity in 43%(p<0.001) children among pathological group. Among physiological group ,murmur persisted on standing position in 40% and decreased in intensity in 80%(p<0.001)

Abnormalities identified on decreasing order of incidence were Atrial septal defect(ASD),significant mitral regurgitation(MR),ventricular septal defect(VSD)and Aortic stenosis(AS)

The positive predictive value of excluding pathological murmur by its complete disappearance on standing position is 98%(95% confidence interval 93%-100%) with a specificity of 93%(95%confidence interval 78%-99%).Sensivity of this simple clinical examination was remarkably lower at 60%(95% confidence interval52%-67%)

Nonpathological or what we call an innocent cardiac murmur result from a normal blood flow through heart and great vessels. The cause of disappearnce of these physiological murmur on switching from supine to standing position is decreased venous return,left ventricular size and stroke volume.

Thus ,by the simple clinical examination of auscutating the heart in supine and then on standing position , a costly and not easily available echocardography may be avoided in most children with innocent cardiac murmur.

REFERENCES

Ann Fam Med. Published online November 13, 2017. Abstract

http://www.annfammed.org/content/15/6/523.full

Pneumonia is responsible for highest number of death in children below 5 years of age worldwide.

The highest number of pneumonia cases in children are found in India.

There are numerous causes of pneumonia including viruses,bacteria,fungi among infectious causes.

Streptococcus peumoniae and Haemophilus influenzae type b(HIB) account for 60% of cases of community acquired pneumonia in Indian children below 5 years of age .

These community acquired bacterial pneumonia are treated by antibacterial agents(ANTIBIOTICS) as a mainstay of treatment.

There is an increasing incidence of resistance of these organisms to existing antibiotics.

Moreover,there are very few antibiotics in the pipeline research to fight these resistant bacteria.

There is urgent need of a new antibiotic to fight resistant community acquired bacterial pneumonia.

World health organisation(WHO) has oversimplified the definition of pneumonia so that no case of pneumonia should be misssed even by ground level health workers.

According to WHO

NO tachypnea=No peumonia

Tachypnea=Pneumonia

Tachypnea with chest retraction=Severe pneumonia

Tachypnea with chest retraction with cyanosis/lethargy/poor feeding=very severe pneumonia

According to the definition and categorization by WHO, pneumonia is overdiagnosed as these findings may be present in children suffering from respiratory diseases other than pneumonia like bronchiolitis and asthma.

Pneumonia in children is diagnosed by a combination of clinical features and investigations.

CLINICAL FEATURES: Fever

Tachypnea:(Respiratory rate>60/minutes below 2 months of age,>50/minute between 2-12 months of age,>40/minute between 1-5 years of age and more than 30/minute between 6-8 years of age)

Tachycardia:(Pulse rate>160/minute between 2-12 months of age,>120/minute between 1-2 years of age and >110 between 2-8 years of age

Chest retraction In the form of subcostal,intercostal and suprasternal retraction

Auscultatory finding: Diminished intensity of breath sound over affected area and deep inspiratory crackles are indication of consolidation in lung parenchyma which is pathognomonic of pneumonia.Bronchial breath sound and wheezes may be heard.

In severe pneomonia, clinical cyanosis may be visible or hypoxia may be detected by pulse oximetry.

INVESTIGATION:Complete blood count may show leucocytosis with predominance of polymorphoneuclear cells.

CRP is significant only if it more than 20mg/dl and blood culture is positive in only 15-20% cases

CHEST X-RAY : it may show nonhomogenous opacity in the lung field indicative of consolidation.Air bronchogram if visible is pathognomonic of consolidation.If opacity is involving a lobe ,it is lobar pneumonia and if the opacity is in bronchial distribution bilaterally, it is bronchopneumonia. Pneomatocele may be visible in Staph Pneumonia.

TREATMENT;The mainstay of treatment of bacterial pneumonia is antibiotics with or without supportive care in the form of intravenous fliud and oxygen if needed.

Oral amoxycillin is the drug of choice in OPD cases.If resistance to it is suspected the doses may be  doubled or a combination of amoxycillin and clavulanic acid may be given.Alternative agents are cefuroxime or cefprozil. Azithromycin should be given only when Mycoplasma or Chlamydia pneumonia are suspected.

In admitted patient the drug of choice is intravenous third generation  cephalosporin.If Staph Pneumonia is suspected Vancomycin or Clindamycin should be given.It should be for 3 days after the child becomes afebrile or for 10 days whichever is later.

There is a new hope for the growing resistance of bacteria to commonly used antibiotics.

Lefamulin belongs to a new class of antibiotics called Pleuromutilins.

Is has the same clinical profile as moxifloxacin which is also used to treat resistant tuberculosis apart from community acquired bacterial Pneumonia.Similar rates of adverse affects has been seen in both the drugs.The efficacy to kill bacteria is also the same.Lefamulin acts by binding to a specific site of bacterial ribosome responsible for protein synthesis.Retapumilin was the first drug of Pleuromutilin group ,approved for human use.This drug Retapumilin is approved for topical use.

Lefamulin has been tried successfully and it is in the final stage of trial . Probably it will hit the the market in the later half of 2018 if approved by FDA.If so,it will be the first drug approved for oral or intravenous use from Pleuromutilin group.Once it will come in the market it may help in treating resistant community acquired bacterial pneumonia and it may spare the drug moxifloxacillin for its use in resistant Tuberculosis as well.

REFERENCES:1.WHO Library Cataloguing-in-Publication Data
Revised WHO classification and treatment of pneumonia in children at
health facilities: evidence summaries.
1.Pneumonia – drug therapy. 2.Child. 3.Health Facilities. 4.Guideline.
I.World Health Organization.
ISBN 978 92 4 150781 3 (NLM classification: WA 320)

2.Expert panel report 3,guidelines for the diagnosis and management of asthma,NIH publicationNo.07-4051,Bethesda ,MD, 2007.U.S Dpartment of health and human services;National institute of health,National heart,,lung and blood institute,National Ashma Education and Prevention Program.

3.Nabriva’s Pneumonia Drug Succeeds in Late-stage Trial – Medscape – Sep 18, 2017.

4. Nelson Text book of Pediatrics ,edition-20

Tiotropium has been studied successfully for control of asthma in children

Asthma is the most common chronic respiratory disorder of children.

It is a pleomorphic disorder characterized by hypersensitivity induced bronchospasm,airway inflammation and variable airway obstruction.

More than 100 genes have been recognised which predispose a child to develop asthma,the most important is 17Q21

Most of the asthmatic children respond very well to inhaled corticosteroid(ICS) alone or in combination with long acting beta agonist(LABA) for the control of asthma symptoms and disabilities.Some children require LTRA in the form of monteleukast as an add on therapy to ICS and LABA for the control of asthma.

Rarely some children do not respond in spite of correct technique of inhalational medications , good compliance,allergen avoidance and comorbidities well addressed.

There is practically no drug available for these children below 12 years of age.

It has been well established that interleukin-4(IL-4) and interleukin-13(IL-13) are responsible for intiation of airway inflammation in asthmatic airways.So,some biological agents are being tried to block these inflammatory initiators.

A new biologic agent DUPILUMAB which blocks IL-4 and 1L-13 has shown promosing results to control severe  asthma in adults.

A study in this regard has been done by Jonathan Corren MD,David Geffen School of medicine,university of California,Los Angeles.According to him, the severity of asthma is best assessed by number of exacerbations in a span of time.He has studied on465,227,122,62 patients with asthma  with 1 0r more,2 or more,3 or more and 4 or more exacerbations respectively in one year.He had given 200mg to 300mg DUPILUMAB at an interval of 2 weeks in addition to ICS and LABA for 24 weeks.

The additioon of Dupilumab has improved the quality of life as assessed by Asthma quality of life questionnaire (AQLQ) and Asthma control questionnaire(ACQ 5,5items)..The impact was seen regardless of eosinophil counts.There was no difference in events of adverse effects among subgroups.Patients with greater number of exacerbations benefitted more.

This study warrants a multicentre study in children so that the children with very poorly controlled asthma even on appropriate therapy may benefit.

Lancet. 2016;388:31-44