PITFALLS IN PEDIATRICS

DR JAYANT NAVARANGE
M.D.,D.C.H.,LL.B.
HON. PEDIATRICIAN->
P.H.R.C.; DEENANATH & SAHYADRI
HOSPITALS; SHREEVATSA; BSSK
ORPHANAGES

Chairman, Medico-legal Cell,

IMA,Maharashtra State, & Pune Br
and I AP, Maharashtra

Pitfalls in Pediatrics: General Principles

1. Failing to keep abreast of changing knowledge and
conceptsIVIG in GBS, Anti-microbial pattern in
your setting
2. Short- cut histories and physical exams; bus
conductor ticket prescriptions
3. Failing to remember the famous dictum- think of
common diagnosis, you will be commonly right and
vice versa! e.g. Asthma, TB in chronic cough rather
than CF, Cong. Cysts etc.
Not revising diagnosis if no +ve result or if further
deterioration after reasonable interval. (Call for added
opinion)

Pitfalls in Pediatrics-History taking:

To underestimate any symptom-headache,
vomiting, cheat pain
To accept others at its face value
Forgetting h/o pets, allergy, fb, birth, pica,
milestones, consanguinity, immunizations
Not to ask history to child directly>3yrs
Deficiencies in exam: BP, Throat, Wt., Ears, AF,
Head , RR, Teeth, Spine, Femorals, Hips,
Perineal area, Anemia, Eyes (cataracts,
movements, phlyctene, pupils) Hips, Gait

Pitfalls in Pediatrics
Failing to refer in time: No one is perfect.
Refer to lab/radiologist/expert/institute in
time. (A case of pregnancy+vomiting all
9mo.-lady died of s.o.l.; puo etc)
Not taking cognisance of the reports you
ordered-(overlooking +ve report of urine
sugar; m.p.)
Relying too much on reports-primary
complex-must read in light of clinical s/s

Pitfalls in Pediatrics
Investigations and Treatment riskier than
disease!-brain lesion biopsy in suspected
tuberculoma; pleural biopsy in t.b.effusion
Tel. Advice on tel. rash diagnosis
Not considering f.b.in diff.diagnosisnose/eye/bronchus/urethra/rectum/esophagus
Lack of records-esp.growth & development,
vaccination and all relevant records
Lack of follow up

Pitfalls in Pediatrics
Ordering non-specific, hectic measures at terminal
moment-analeptics, cardiac massage
Over hospitalisation-will spread nosocomial
infections
Non informing/educating patients about
disease/treatment: t.b.; cancer; nephrotic etc.
Not imparting preventive advice: vaccines;
nutrition; diarrhoeas; addictions; accidents etc;
detecting and advising t.b./typhoid/HIV contacts

Pitfalls in Pediatrics(Surgery)
Not ruling out medical conditions before operating, e.g.
Pneumonia/Effusion/ Henchs purpura in opening
acute abdomen
Under/Over appendicitis-all ages
Shying away from bone marrow or LN biopsies in
Anemias; FUO; Nodes; Masses
Unnecessary surgeries-tongue tie; labial adhesions;
meningocoeles with paralysed legs; umbilical hernia
Missing surgical causes-of chr. Diarrhoea; colics;
constipation; bleeding pr; UTI; recurrent RTI/CNS inf.
Missing to examine genitalia- torsion/inf./hernias etc.

Pitfalls in Pediatrics(Psychology):
Over labeling functionalAbnormal
behavior/movements due to hepatic
precoma, CNS tumors, chorea
Missing psy.causes for physical S/S
Failure to recognise childs feelings
Failing to realise that there are more
problem parents and homes than problem
children- nail biting; bruxism; enuresis;
encopresis

Pitfalls in Pediatrics(Psychology):Cont.
Failing to advise parents to set realistic and controllable
goals
Giving medicines for IQ/Memory/ Mental
Retardation etc.
Believing that mild punishment/deprivation e.g. movies/tv
are critical determinants in behavioral development
Failing to recognise variability of normal child behavior50%children lie or cheat on occasions

Pitfalls in Pediatrics-Neonatology:
Failing to obtain X-ray chest for RS
distress; Abdomen for bilious vomiting; kull
for cephalhematoma for #skull under it
Draining cephalhematoma
To neglect the most imp. Symptom- failure
to suck (of any duration)-Sepsis/meningitis
Failing to note that sick neonate is usually
afebrile or hypothermic
Faling to give vitamin K to all newborns

Pitfalls in Pediatrics-Neonatology:Continued
Failing to note significance of jaundice within 24
hrs and jaundice after or persisting > 14 days or
recurrences
Failing to realise that CHD can be murmurless and
vice a versa
Treating transitional diarrhoea or non-specific
vomiting, when wt gain is ok
Not checking wt at each visit and head/ht
Postponing surgery of hernia
Failure to note that seizures can be very subtle

Pitfalls in Pedia.- Infant Feeding:

Not preparing for and insisting on breast
feeding- it is both- art and science
To advise stopping BF for vomiting/ colics/
diarrhoea or for any illness or maternal Rx
To advise supplementary water or anything
before 4 mo and not introducing weaning
after 6 mo.
Milk intake > 1 Litre/day
Not checking Hb at 6-9-12 months

Pitfalls in Pediatrics-History & Exam.:

Assessing jaundice, cyanosis or skin rashes
in fluorescent lamp light-call in daylight
Not reassessing or rechecking (reevaluating)at rechecks-especially if
symptoms are not improving or persisting
Believing in fevers when child is ok- not
taking temp or charting if alleged f.u.o. and
investigating and treating

Pitfalls in Pediatrics-R.S.
To miss h/o chest pain, tracheal shift
Importance of unilateral wheezing, Air entry, dull
note
Non-responding asthma-acidosis, infection,
pneumothorax or dehydration
To label chr. S/s as TB or Asthma
Not considering eosinophilia, GER, f.b. etc
Shying away from chr. Cough as asthma
Shying away from inhalation steroid Rx

Pitfalls in Pediatrics:Cardiovascular Sy.

Most major CVS anomalies are murmurless

Harsher the murmur, minor the defect!
Relying too much on ECHO etc.
Failing to note Femoral pulses, cyanosis,
BP, Signs of Bact. Endocarditis, CCF etc
Not giving prophylaxis for Rh. Chorea
Not looking for other anomalies!

Pitfalls in Pediatrics:GIT

To discontinue oral feeds, esp. Breast feeds in

AGE/Chr.diarrhoeas/PEM
To consider simple Viral Hepatitis if jaundice is
recurrent or prolonged> 6 weeks
To rely on skin turgor as a sign of dehydra.
To rely on fixed fluid calculations-it has to be
assessed frequently-its a dynamic process
To use several drugs for diarrhoeas
Try to find cause of vomiting

To neglect or over-treat abdominal painacute, chronic or recurrent

Pitfalls in Pediatrics-GUT:
Not examining genitalia, B.P. & Urinary stream
in dysuria, UTI etc.-we had a child 1yr with
fever from neonataal period due to tight
phimosisbilateral hydronephrosis!
Treating AGN with steroids
Confusion bet. AGN, NS and UTI
Not withholding bakery products and fruits in
AGN, HTN, ARF
AGN needs hospitalization
UTI in males-MUST investigate thoroughly.
60% have anomalies(surgical)

Pitfalls in Pediatrics-Vitamins Treating with repeated doses of massive vit.

A and vit. D-they are toxic
Prescribing vitamin supplements for
anything
Forgetting that vit. D is needed by growing
child and not a marasmic one!
Not realising that Night blindness/xerosis/
keratomalacia are medical emergencies
Check tonics,contents and claims!

Pitfalls in Pediatrics:Neurology1
To diagnose simple Febrile seizures in a child
<6months or > 5 years
To give AEDs for simple Febrile seizures
Labeling mental deficiency on basis of single
delayed milestone, or not checking prematurity
or in 1 IQ/DQ assessment
To miss CNS infection just because neck
stiffness or fever is not manifest

Pitfalls in Pediatrics:Neurology2
To miss characteristic vomiting of ICTprojectile, no nausea, sudden, morning
Missing importance of sudden squint or head tilt, falls - it
may be SOL in CNS
Guillain-Barre does occur in infants-children!
Not doing head measurement, auscultation,
transillumination, fundoscopy
Plantars are extensor () up to 2 years!
EEG can be normal in epilepsy and vice a versa- basis of
AEDs is CLINICAL!

Pitfalls in Pediatrics-Endocrines
Failure to appreciate great variability of growth and
sexual maturation-charting imp.
FTT < 5yr-nutritional/infections etc-non-endocrinal
except hypothyroidism
Obesity is 99% non-endocrinal
IDDM: treating with OHA, low cal diet
Gynecomastia in 60% of normal boys
Use of thyroid hormone in Downs, obesity, f.t.t.,
stunting, scholastic backwardness, fatigue

Pitfalls in Pediatrics:Infections
Not realising distinction bet. Infectious
disease and Contagious disease
Not knowing period of infectivity
Missing Osteomyelitis in a case of Joint
Pain and/or Swelling
PUO-Confirm its existence. Then UTI, TB.,
Deep abscess, Amoebic Hepatitis, HIV,
Collagen disorders, Malignancy, Endocrine.

Pitfalls in Pediatrics:Infectionscontinued:
Forgetting that all fevers are not due to infections and

Also forgetting that (serious) infections do exist

without fever (esp. in infants & olds)
Over treating with antimicrobials(AMs)
Not using rational and logic in Ams
Dosage and Duration of Ams deserve more attention
Too much reliance on Culture-Sensitivity reports

Pitfalls in Pediatrics:Immunisations
To start vaccinating all over again if interval
between consecutive doses lapse in time
Not maintaining proper position in freeze
Fomenting injection site!
Recommending against pulse polio
Insuring full protection from vaccine
preventable diseases by vaccine doses
Forgetting to insist on follow up doses

Pitfalls in Pediatrics:Treatment1
Failing to note h/o Allergy on first page
Giving false credit of response to medication, which
might occur even otherwise!
Too much Pharmaco-dependence- both patents and
doctors
Treating symptoms only
Failing to treat symptoms
Anabolic steroids for height gain!-in fact they lead to
stunting!(by early epiphiseal closure)

Pitfalls in Pediatrics:Treatment2
Inducing vomiting in Kerosene or Corrosive poisoning
(recent case in DMH-2006)
Using empirical, unindicated, costly, dangerous,
hypothetical or experimental drugs e.g. encephabol,
placental extracts
Using anti-histaminics (AH) in asthma, collagen
disorder
Use of topical AH-Caladryl must be banned! They are
all potent sensitizers!

Pitfalls in Pediatrics:Pathology1
Over or Under use of laboratory
To treat investigations and not patient!
Believing that normal WBC count rules out
lukemia
Attaching undue merit to Mantoux test
Under doing Bone marrow and CSF exams.
RA factor is ve in >85% children of RA!

Pitfalls in Pediatrics:Pathology2
Wrongly interpreting pus cells in urine or
stool reports
Wrong interpretation of sugar, fat.
Undigested particles, cysts of E.histolytica
Culture report of commensals!
ALWAYS interpret in clinical context!

Pitfalls in Pediatric Orthopedics

Forgetting that most fractures heal with
minimum treatment
Infections of bones and joints are common
There can be referred pain-esp. kneehip
Tumors are common-and highly malignant
Metabolic diseases are common. So also
storage disorders
Absent bones can be imp. Clues to
hematologic conditions
Neglecting leg pains, limps etc.(Perthes,
spine anomalies etc.)

Pitfalls in Pediatrics:Dentistry
Unscientific approach->Caried tooth need
not be treated- they will fall off!
Missing dental infections as a source of
chronic ill health, Bact.endocarditis etc.
Giving vit.D for delayed eruption, caries
Not advising preventive fluoride pasing
every 6 months
Malocclusion needs orthodontic treatment

Pitfalls in Pediatrics:Ophthalmology
Not looking for Cataracts, Squints
Delaying needling NL duct blocks
Using Steroid combinations for
conjunctivitis and other infections
Medical indications for contact lenses if
myopia > -3; kerartotomy>21yrs only
Eye is an extension of CNS!It is mirror of
many systemic disorders too!

THANK
YOU