This occurs most frequently between 1 and 4 years. At these ages children are active , curious and in strong negativistic phase. Children of this age have strong urge to put things in their mouth both for identification and for oral gratification.
Accidental poisoning is twice as common in boys as in girls because boys are more aggressive and exploratory in nature.
Medicinal agents are frequently ingested by young children. Tranquillizers , contraceptives and antihistaminic tablets have been ingested more frequently by children.
Household cleaning agents such as detergents , bleaches , disinfectants , polishes are taken. Turpentine is poisonous to heart and kidney.
Poisonous plants are known seasonal hazards.
Kerosene poisoning is common in areas where this oil is used for heating and lighting. It is responsible for 40% of poisoning cases in children in India.
Other poisons include alcohol , pesticides , iron and materials containing lead.
Poverty and high social mobility increase likelihood of accidental poisoning since safe keeping of toxic preparations is less easy , parents likely to be less knowledgeable about risks , supervision may be less strict in very poor families hunger may be stimulus for ingestion of harmful substances.
Children of psychologically disturbed families are also at greater risk.
Children may be poisoned by adult who administers toxic substance by mistake. Dettol in water is mistaken for milk , hexachlorophene emulsion for milk of magnesia and salt for sugar resulting in hypernatremia.
Occasionally poisoning in children may be non accidental , form of child abuse.
Clinical features :
First indication is when mother discovers child with half empty bottle or with contents of box of tablets scattered on floor.
Smelling breath , inspecting lips and mouth for burns , discoloration or particles of tablets , examination of urine or vomited material may help to substantiate diagnosis.
Examination of gastric contents is most satisfactory way of identifying ingested poison.
General condition of child should be noted especially his level of consciousness and excitement ,incoordination , tremors , twitchings and unusual behavior.
Pattern of breathing should be observed.
Eyes examined for pupillary size and reaction.
Color changes , diarrhea , vomiting , convulsions and loss of consciousness.
Possibility of poisoning must be considered in differential diagnosis of any acute illness especially when there are unexpected or unusual signs.
In some cases effects of poisons are delayed and signs of hepatic or renal failure or inhalation pneumonia may develop long after period of initial observation.
Induced emesis is more effective than spontaneous vomiting or gastric lavage in removing ingested material. Therefore vomiting should be induced by administration of 15 ml ipecac accompanied by 200 ml water. Induced emesis is contraindicated in depressant drugs , kerosene poisoning , corrosive poisoning , unconscious child and when he is having convulsions.
If emesis is contraindicated then careful gastric aspiration followed by lavage using small quantities of water , saline or weak solution of sodium bi carbonate.
Few poisons have specific antidotes. When acids are ingested milk may be given to drink. When alkalis are ingested vinegar and water may be given.
In some cases poisons may be inactivated by giving activated charcoal powder mixed with tap water.
Specific antidote :
Naloxone for opium and its derivatives.
Atropine and pralidoxime for organophosphorus compounds found in insecticides.
Desferrioxamine for iron.
Sodium calcium edetate for lead.
Dimercaprol for mercury.
In severe poisoning treatment for shock and circulatory and respiratory insufficiency may be required.
Sudden unexpected cot death
Cot deaths constitute greatest single cause of death between 1 month and 1 year.
Apnea is the feature of disorder. Mechanical obstruction of respiratory passages by aspiration , suffocation , laryngospasm , allergic laryngeal swelling due to cow milk protein allergy , disturbed central ventilatory control or diminished ventilatory drive have been incriminated.
Other etiological factors include cardiac arrhythmia and conduction defects , metabolic disturbances (hypomagnesimia , hypernatremia , hypocalcimia) biotin deficiency leading to hypoglycemia due to biotin dependent enzyme pyruvate carboxylase deficiency , hypothermia and hypothalamic hypofunction. All these factors lead to apnea.
75% of cot deaths occur between 2nd and 6th month of life. Second infant in family is most likely to be affected. There is slight preponderance of males and low birth weight babies.
Premonitory symptoms are often present one to two days before death occurs. These symptoms are of 4 types :
Respiratory – snuffles , cold , cough , rapid wheezy or noisy breathing.
Gastrointestinal – diarrhea , vomiting.
Cerebral – drowsiness , irritability , altered or excessive crying.
Non specific – fever , sweating , reluctance to feed.
Death usually occurs silently suddenly and unobserved. Usually there is no sign of distress.
High risk pregnancy is associated with increased incidence of SIDS.
Good antenatal care of mother , avoidance of smoking and drugs taking during pregnancy. Good obstetric care , breast feeding and close observation for several days after minor illness.
In near miss cases home respiratory monitoring with alarm system to indicate apnea is justifiable. Stimulation of baby in early stages of apnec attack always results in reestablishment of respiration.
Falls from stairs , low windows opening outwards , insecurely fastened car doors , uncovered wells or pits are sources of falls. Small children often fall out of bed , slip on polished floor or trip over carpets.
Children are at highest risk of falling during second year of life when they have learned to walk and explore but are still poorly coordinated.
After 5 years of age falls are usually due to risk taking like tree climbing.
If head strikes first injury is likely to be serious especially if surface struck is hard.
Accidental smothering of healthy infant by bed clothing is rare event. Preterm and sick infant is vulnerable. It is wise to advocate light covers for infants and banish pillows.
Accidental suffocation of newborn by inhaled feeds is largely avoidable by skilled nursing.
Older infants and toddlers are at increased risk of suffocation from inhaled foreign bodies especially toys and from choking on food.
Plastic bag may cause suffocation by covering nose and mouth.
Aspiration of foreign body may cause obstruction of respiratory passage and death. Three different maneuvers have been described for treatment of obstructing foreign body :
– Back blow and chest thrust. (Recommended by American Academy Of Pediatrics).
Place child face down on your knee and forcefully give four back blows. If this does not relieve obstruction give four chest blows.
– Heimlich maneuver consists of
– Shoulder caudal maneuver.
These maneuvers are not required if child is able to cough , breath or speak. Patient’s natural cough will more effectively clear airways than any artificial assistance.
Drowning and submersion
In healthy struggling child laryngeal spasm may prevent water from entering lungs and loss of consciousness is due to cerebral anoxia (dry drowning). If water is inhaled it acts as irritant to lungs , respiratory passages fill with foam and there is respiratory failure with cardiac arrest (wet drowning). If water is muddy or polluted , child may be revived but may develop later progressive pulmonary edema and pneumonia. Resuscitative measures aimed at establishing adequate pulmonary ventilation must be instituted immediately , combined with cardiac massage.
Exposure , immersion and hypothermia
Clinical features of hypothermia include staggering gait , confusion and unconsciousness , pallor , cold to touch and rigidity.
Most effective treatment of hypothermia is to immerse patient in bath of water at 40-44°C rectal temperature. Blood pressure should be recorded.
Management of injuries
Road and traffic injuries :
These cause multiple injuries especially to internal viscera. Death is frequently due to fracture of skull.
First 20 minutes are crucial in determining outcome of multiple injuries
Sequence of events in management of multiple trauma :
1 . Immobilize neck :
Place sandbags against both sides of face and apply wide adhesive tape to forehead securing head to stretcher.
2 . Remove clothing :
Cutting off quickly with large scissors for proper evaluation of injuries.
3 . Sixty second physical :
Airway , breathing , circulation. Cardinal sign of airway obstruction is air hunger.
Upper airway obstruction is relieved by chin lift. For lower respiratory obstruction tracheostomy is needed.
Ventilation is checked by auscultation. Pneumothorax is relieved by immediately inserting needle.
Adequacy of circulation is judged by skin color and time required for capillary refill of nail bed. Major external hemorrhage should be stopped.
4 . Venepuncture :
Tests should be withheld. Essential studies are hematocrit , blood group and serum amylase.
5 . Nasal oxygen :
With nasal prongs at rate of 2 Litre per minute.
6 . Venous access :
Rapid repair of hypovolemia. Venesection may be required at saphenous vein.
7 . Fluid resuscitation by Ringer lactate in emergency.
8 . Cervical spine X ray :
To assess integrity of cervical spine.
9 . Insert Foley catheter :
For measurement of urinary volume as indication of organ perfusion.
10 . Endotracheal intubation :
In absence of effective respiratory efforts.
11 . Insert nasogastric tube :
All pediatric trauma patients have gastric dilatation.
12 . Peritoneal lavage :
As diagnostic test for abdominal bleeding and perforation of intestine.
13 . Insert arterial line :
For measurement of blood gas tension.
14 . Head to toe examination :
To detect signs of trauma.
15 . History :
It should include details of immunization , drug allergy and current medication.
16 . X ray :
Chest , pelvis , long bones and CT scan of skull.
17 . Diagnosis :
To establish order of treatment.
Injuries can occur at all ages but very young and very old people are especially susceptible. They have physical vulnerability , lack of coordination and inability to avoid or escape from danger.
Young children are curious and have desire to explore which may expose them to hazards.
In mid childhood spirit of adventure and bravado leads them into perilous situations. Their experience makes it difficult for them to asses risk and to recognize danger when it approaches.
Young children exhibit negativism and older children may have suppressed hostility to their parents which lead them to incur risks in deliberate defiance of parental wishes.
Negligence or ignorance on part of attendants may precipitate injuries to predisposed children. Environment also contributes to injuries. Home has certain hazards for children such as stairs , heating and cooking equipment , sharp instruments etc.
Other environmental hazards are rivers , ditches containing water , animals , falls from trees etc.
As child grows older his environment enlarges and road traffic injuries and drowning become more. Certain children are injuries prone. They are active , exploratory and illdesciplined , tending to play roughly and competitively. They have poor self control , impulsivenes and carelessness which impair their capacity to make decision quickly and so to cope successfully with hazards.
Injuries repeaters may be at increased risk due to environmental stress or family disorganization.
Differential diagnosis must include child abuse.
Injuries occur independent of will of child caused by quickly acting extraneous force and manifesting itself by damage to body and mind. Injuries are determined by both environmental circumstances and personal behavior and have clearly recognizable epidemiologic pattern.
A . Age and gender incidence :
Injuries are 2-3 times higher for boys than girls at all ages. Boys are more liable to injuries arising from outdoor activities and girls to injuries at home.
At all ages and in both sexes motor vehicle injuries are leading cause of death. Drowning second in boys and burns second in girls.
B . Season and time of day :
Domestic injuries are related to household activities and are likely to occur at meal times.
Road side injuries reach peak in late afternoon when children come out of school.
Falls cuts and other injuries are more common at weekends in summer.
Burns are more frequent in winter. Drowning commoner in summer.
C . Low social class and maternal psychiatric illness increase risk of injuries.
Causes of injuries
1 . Under one year :
– Cot death
– Inhaling or swallowing toys and other small objects.
2 . One to four year of age :
– Burns and scalds.
– Traffic accidents.
– Cuts with sharp instrument.
– Crushing injuries.
– Animal bites.
3 . School age :
– Bicycle injuries.
– Environmental injuries.
4 . Adolescent age :
– Road traffic accidents.
– Hazards of outdoor play.
1 . Hearing loss :
Audiogram reveals mild to moderate conductive loss. However there may be sensorineural component. Persistent conductive hearing loss may result in impairment of cognitive , language and emotional development of children.
2 . Perforation of tympanic membrane :
This is usually central. Otorrhea follows. Treatment is with antibiotic cortisone otic medication. Healing follows cessation of suppuration. If it does not heal then tympanoplasty can be done.
3 . Acquired cholesteatoma :
It is sac like structure lined by keratinized stratified squamous epithelium with accumulation of desquamating epithelium or keratin within middle ear. Tympanomastoid surgery is indicated.
4 . Mastoiditis :
X ray reveals cloudy mastoid. There is pain tenderness edema erythema of post auricular area. Pinna is displaced inferiorly and anteriorly. It requires immediate tympanocentesis , myringotomy and systemic antibiotic. If it progresses it will form subperiosteal abscess. Infection may also break through mastoid tip into neck (Bezold abscess) or fistulize into external ear canal.
5 . Petrositis :
Triad of otitis media with effusion , paralysis of lateral rectus muscle and pain in homolateral orbit or retroorbital area with headache constitutes petrous apicitis or Gradenigo syndrome.
6 . Adhesive otitis :
Mucous membrane is thickened by proliferation of fibrous tissue which impairs movement of ossicles and thus results in irreversible conductive hearing loss.
7 . Tympanosclerosis :
This is characterized by whitish plaques on tympanic membrane and nodular deposits in submucous layers of middle ear. There is hyalinization with deposition of calcium and phosphate crystals. Conductive hearing loss may result from ossicles embedding in deposits.
8 . Ossicular discontinuity :
This is due to rarefying osteitis. Long process of incus is commonly involved. Crural arch of stapes , body of incus or manubrium of malleus may also be eroded.
9 . Facial paralysis :
Immediate surgical intervention is needed when facial paralysis develops in child who has chronic suppurative otitis media with or without cholesteatoma.
10 . Suppurative labyrinthitis :
There may be vertigo tinnitus nausea vomiting hearing loss and nystagmus. Antibiotic and labyrinthectomy are indicated to prevent spread to cranial cavity.
11 . Intracranial suppurative complications :
– Focal encephalitis.
– Brain abscess.
– Sinus thrombophlebitis.
– Extradural abscess.
– Subdural abscess.
– Otitic hydrocephalus.
Infection spreads from middle ear and mastoid to intracranial structures through vascular channels (osteothtombophlebitis) , direct extension (osteitis) or performed pathways eg round window , previous skull fracture and congenital or surgically acquired bony dehiscences. Child develops
Children with intracranial infection (recurrent meningitis or brain abscess) should have middle ear-mastoid disease ruled out as origin.
Acute otitis media
Clinical manifestations :
Child suffering from acute upper respiratory tract infection suddenly develops otalgia , fever and hearing loss.
Examination with otoscope reveals hyperemic , opaque and bulging tympanic membrane of poor mobility.
Purulent otorrhoea may be present.
Sometimes presentation is like Pyrexia of undetermined origin.
Aspiration of middle ear (tympanocentesis) has following indications :
– Seriously ill or toxic child.
– Unsatisfactory response to antibiotics.
– Suppurative aural , intratemporal or intracranial complications.
– Otitis in newborn , very young infant.
– Immunodeficient child.
Streptococcus pneumonia is commonest cause. Other organisms are H. Influenzae , beta hemolytic streptoccus , staphylococcus aureus.
In neonates gram negative organisms.
Erythromycin 50 mg per kg per day. Or amoxycillin clavulinic acid.
Supportive therapy includes analgesic antipyretic and antihistamine.
Myringotomy should be performed if pain and fever continue after 48 h of starting therapy.
Follow up should be done after 2 weeks. Complete clearing of effusion may talk 6 weeks or longer.
Recurrent acute otitis media
This may occur with any acute respiratory infection or acute exacerbation of chronic otitis media. In many children underlying cause is not evident but myringotomy with insertion of middle ear ventilation tube is helpful. Prophylactic antibiotic is indicated between attacks. Other preventive measures are hyposensitization and adenoidectomy.
Chronic otitis media
Effusion may be serous , purulent or mucoid.
Retracted or convex tympanic membrane is seen. It is usually opaque but when it is translucent air fluid level or air bubbles may be seen. Mobility of ear drum is impaired. When negative pressure in middle ear is extreme it causes ‘atelectasis’ of tympanic membrane.
Auditory acuity is decreased. Systemic symptoms are absent. Behavioural disturbance may occur due to child’s inability to communicate. Feeling of fullness in ear , tinnitus and vertigo may be present.
Audiometry may be helpful in establishing diagnosis. Tympanometry is more reliable.
Efficacy of antibiotics , steroids , decongestants and antihistamines is not established. Occasionally attempts at middle ear inflation by Valsalva method are successful.
In most children effusions are self limited. If effusion persists for 3 months or longer or if there have been frequent episodes of acute otitis media patient requires further evaluation for respiratory allergy , adenoidal obstruction , immunologic disturbances or abnormalities such as submucous cleft palate or tumor of nasopharynx.
Myringotomy with aspiration of middle ear fluid is indicated if effusion has persisted for 3 months. Insertion of ventilation or tympanostomy tube may be necessary to allow middle ear mucous membrane to return to normal and to prevent subsequent recurrence of effusion. This is also helpful in patients with atelectasis of tympanic membrane when pain , hearing loss , tinnitus and vertigo are present. Ventilation tube may prevent permanent structural damage and cholesteatoma. In selected cases allergic hyposensitization and adenoidectomy may be beneficial.