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liable to be mistaken for an inguinal hernia.
 The swelling moves downwards and becomes less mobile if the testis is pulledgently
downwards.
 Hydrocele of canal of Nuck is similar condition in female. The cyst lies in relation to the
round ligament and is always at least partially within the inguinal canal.


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 “Fatty forty flatulent fertile female” is the classical description ofcholelithiasis.
 R ight upper quadrant epigastric pain, dyapepsia, nausea, vomiting.
 Murphy’s sign.
Salient features
Investigations
Ultrasound abdomen, total and differential count, liver function test
Surgical treatment
 Definitivetreatment ischolecystectomy in symptomatic and asymptomatic patients
w ith diabetes or  asolitarylarge stone or multiple small stones with wide cystic
duct or porcelain gallbladder or anxious patients. Ifthe patient comes after48 hours
manage conservatively and cholecystectomy after6-8 weeks.
 In case of acutecholecystitis, empyema gallbladder, andstonesin the CBD following
treatment is instituted.
Pharmacological treatment
 Maintenance IV fluids


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treatment is instituted.
Pharmacological treatment
 Maintenance IV fluids
 Inj.ciprofloxacin(infusion 100m g/50 ml) 100 ml IV twicea day and Inj. gentamicin(40
mg /ml) 2ml IV 8 hourly.
 In case anaerobicbacterial infectionis suspectedor anticipated, giveInj. metronidazole
(500 mg/l00ml) 100 ml IV 8 hourly.
 Inj. diclofenac sodium (25 mg/m l) 2 -3 ml IM SOS or 6 hourlyor Inj. pentazocine (30
mg/m l) 1m l IM SOS .
 Inj.hyoscinebutylbromide (20 mg/ml) 1ml IV SO S.
 In patients having obstructivejaundice, addInj. vitaminK (10 mg/ml) 1 ml IM once or
twicea day tillprothrombin time reaches toa satisfactory level.
 Antibiotics areusuallystoppedafter5-7 days unlessthepatienthas evidence ofpersistent
infectionor has indwelling tube(e.g., T -tube).
Patient education


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infectionor has indwelling tube(e.g., T -tube).
Patient education
 To avoid fattyand fried meals for3 months.
 Althoughambulation isencouraged as early as possible,heavy physical exertionshould be
avoided for 2 weeks (after laparoscopic cholecystectomy)and for 3 months after
conventional cholecystectomy.
 If T -tube has been placed, it should beremoved after 2-3 weeks, after ensuring thatthe
CBD ispatent,non dilatedand thereis free flow of contrastinto theduodenum during T-
tube cholangiography.


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Surgery
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 Disease may be entirely asymptomatic.Abdominal lump in right upper quadrant.Pain
may be characterized as heaviness in abdomen.
 Obstructive jaundice when daughter cyst may communicate with bil iary tree.
Anaphylactic shockif cyst ruptures into peritoneal cavity.
 Jaundice, itching, anorexia, weight loss, clay coloured stools, dark urine
 Abdominal lump, abdominal examination, look for palpable mass, liver,
 G eneral examination: Jaundice, cachexia
HYDATID DISEASE OF LIVER
It iscaused byEchinococcus granulosusand Echinococcus multilocularis
Salient features
Classification by WHO
 Group 1-Active group-cysts larger than 2 cm and often fertile
 Group 2- Transition group- cysts starting to degenerate and entering a transitional stage


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 Group 2- Transition group- cysts starting to degenerate and entering a transitional stage
because of host resistance or treatment but mat contain viable protoscolices
 Group 3- Inactive group- degenerated, partially or totally calcified cysts, unlikely to contain
viable protoscolices
Investigations
 TC and DC show eosinophillia.ELISA can point toward diagnosis.Ultrasound and CT scan
are the investigations of choice. CT scan shown smooth space occupying lesion with several
septa
Pharmacologicaltreatment
 Tab.albendazole 400 mg TDS for 28 days repeated for 3 cycles.
Surgical treatment
 PAIR -Puncture, Aspiration, Injection (of a scolicidal agent), Reaspiration
 Radical or partial pericystectomy
 Hepatic segmentectomy


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 PAIR -Puncture, Aspiration, Injection (of a scolicidal agent), Reaspiration
 Radical or partial pericystectomy
 Hepatic segmentectomy
 Scolicidal agents used for surgery: hypertonic saline 15%,cetrimide 3%
OBSTRUCTIVE JAUNDICE
Jaundice, also known as hyperbilirubinemia causes increased levels of bilirubin in the
extracellular fluid. Concentration of bilirubin in blood is normally below 1.2 mg/dL. A
concentration higher than 2.5mg/dL (>50µmol/L) leads to jaundice. It can be caused by
choledocholithiasis, periampullary mass, billiary atresia, cholangiocarcinoma, Mirizzi syndrome
Salient features


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Surgery
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Investigations
 S. bilirubin: total, direct, indirect, hyperbilirubinemia with increased direct bilirubin,PT with
INR, elevated, SGPT, SGOT- can be normal or elevated, SAP- increased more than 3 folds,
CA 19 -9, elevated in periampullary cancers
 USG -Abdomen, MRCP, CECT -Abdomen, ERCP
Non pharmacological treatment
Low fat, high carbohydrate diet
Pharmacological treatment
 IV fluids to maintain hydration and Correction of electrolyte imbalance
 Inj. vitamin k
 Fresh frozen plasma  when indicated
 Prophylactic antibiotics, Inj. cefotaxime 1 gm IV 8 hourly
Surgical treatment
 ERCP with sphincterotomy and stenting, followed by cholecystectomy
 For choledocholithiasis,cholecystectomy with CBD exploration
 For stones not amenable for retrieved by ERCP


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 For choledocholithiasis,cholecystectomy with CBD exploration
 For stones not amenable for retrieved by ERCP
 Whipple procedure (pancreaticoduodenectomy), for resectable periampullary mass
 Bypass procedures (hepaticojejunostomy with/without gastrojejunostomy)for unresectable
periampullary mass
INTESTINAL OBSTRUCTION
Causes
 Intraluminal-impaction, foreign bodies, bezoars, gall stones
 Intramural-stricture, malignancy
 Extramural-bands/adhesion, hernia, volvulusintussusecption
 A dynamic-paralytic ileus ,mesenteric vascular occlusion ,pseudo obstruction
Mechanism of obstruction
V olvulus, incarceration, obstruction,intussusceptions
Causes of strangulation
 External: hernial orifices, adhesion/bands
 Interrupted blood flow: volvulus,intussusceptions


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Causes of strangulation
 External: hernial orifices, adhesion/bands
 Interrupted blood flow: volvulus,intussusceptions
 Increased intraluminal pressure: closed loop obstruction
 Primary: mesenteric infarction


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Surgery
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 A cute-sudden onset severe colicky central abdominal pain,distension,early vomiting,
constipation
 A cute on chronic-shorthistory of distension and vomiting against a background of pain
and constipation
 C hronic inlarge bowel obstruction with lower abdominal colic ,absolute constipation
followed by distensionsubacute implies incomplete obstruction
 O ther manifestation are dehydration, hypokalemia pyrexia, abdominal tenderness,
clinical features of strangulation; constant pain, tenderness with rigidity,shock
 The patient resides or recently visited an endemic area. Patient presents in 2nd or 3rd
week of illness.
 Patients present with high temperature and very toxic, Ross spots,abdominal pain,
malena, diarrhoea,abdominal tenderness andguarding.
Salientfeatures


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malena, diarrhoea,abdominal tenderness andguarding.
Salientfeatures
Investigations
 X ray abdomen in standing position, shows multiple air fluid levels
 Total and differential counts
 Ultrasound abdomen
 Contrast enhanced ct scan abdomen with pelvis
Non surgicaltreatment
 Nasogastric decompression, correction of dehydration, correction of electrolytes imbalance
and broad spectrum antibiotics
Surgicaltreatment
 Exploratory laprotomy with adhesiolysis, resection of non viable intestine or extirpation of
obstructing lesion.
TYPHOID PERFORATION
It iscaused bySalmonella typhi.
Salient features
Investigations
TC and DC shows relative neutropenia, Widal test, Blood and Stool culture, X ray abdomen
standing shows free gas under diaphragm
Non pharmacological treatment


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standing shows free gas under diaphragm
Non pharmacological treatment
 Patient should be admitted to intensive care unit
 Vigorous resuscitation of fluids


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 Weight loss, chronic cough, malaise, evening rise of temperature with sweating, vague
abdominal pain with distension, alternating constipation and diahrrea.
 May present with features of peritonitis with perforation orobstruction. Doughy feel of
abdomen.
 Inj.ceftriaxone 2 gm loading dose followed by 1 gm IV 8 hourly
 Tab.metronidazol 400 mg IV 8 hourly
Surgical treatment
 Emergency exploratory laparotomy
 Commonest site of perforation is terminal ileum
 Having found a perforation, look for others
 In the very ill patient, look for some type of extoriorisation
 Close the peritoneum and leave the wound open forsecondary healing
SMALL BOWEL TUBERCULOSIS
Salient features
Investigations
 Hemogram shows anemia, raised ESR and CRP, positive sputum culture. Ultrasound of


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SMALL BOWEL TUBERCULOSIS
Salient features
Investigations
 Hemogram shows anemia, raised ESR and CRP, positive sputum culture. Ultrasound of
abdomen shows localized collection.
 Chest X Ray show pulmonary infiltrates.
 Barium meal and follow through shows multiple small bowel strictures in ileum and
subhepatic caecum.
Surgicaltreatment
 Patient should ideally be treated under combined care of physician and surgeon. Vigorous
supportive and full drug treatment is mandatory in all cases. Symptomatic strictures are
treated by appropriate resections.
 Acute intestinal obstruction from distal illeal stricture is treated by thorough resuscitation
followed by side to side illeo-transverse bypass.Once the patient has recovered with medical


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followed by side to side illeo-transverse bypass.Once the patient has recovered with medical
treatment, then the second stage definitive procedure of right hemicolectomy is done.
 One stage resection and anastomosis can be done if the patient’s general condition permits .
Perforation is treated by appropriate local resection and anastomosis or exteriorization if the
condition of the patient is very poor, that is later followed by restoration of bowel continuity
after patient is fully recovered of anti-tuberculous therapy.


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 Constipation, sharp agonizing pain during defecation, bright streaks of blood in stools.
 Ulcer at the lower end of the anal canal seen when tightly closed puckered anus is
stretched apart.
ANAL FISSURE
Salient features
Pharmacological treatment
 Lignocaine jelly or ointment (5%) applied locally 3-4 times a day;
 Tab. metronidazole 400 mgfor 5 days, twice a day.
 Tab ibuprofen 400 mg one tablet 8 hourly
 Sitz bath (warm water withpovidone iodine) twice a day
 Isapghula husk 1-2 teaspoon in water one or two times a day for control ofconstipation and
straining during defecation Or
 Liquid paraffin (5-15 ml) at bed time for one month, if no relief with local lignocaine,
application
Surgicaltreatment


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 Liquid paraffin (5-15 ml) at bed time for one month, if no relief with local lignocaine,
application
Surgicaltreatment
 Aim of therapy is to cause complete relaxation of the anal sphincter that will relievepain and
slowly heal the fissure.
 Anal dilation under general anaesthesia.
 Fissurectomy and sphincterotomy if needed.
FISTULA IN ANO
A fistula-in-ano is a hollow tract lined with granulation tissue, connecting a primary opening
inside the analcanal to a secondary opening in the perianal skin. Secondary tracts may be
multiple and can extend from the same primary opening. Fistula-in-ano is nearly always caused
by a previous anorectal abscess.
Salient features
 Patients often provide a reliable history of previous pain, swelling, and spontaneous or


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by a previous anorectal abscess.
Salient features
 Patients often provide a reliable history of previous pain, swelling, and spontaneous or
planned surgical drainage of an anorectal abscess. Signs and symptoms of fistula-in-ano,
in order of prevalence, include the following perianal discharge, pain, swelling, bleeding,
diarrhea, skin excoriation, external opening


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 Bleeding per rectum, pruritus ani, something coming out per rectum, constipation.
 Per rectal examination and proctoscopy  shows haemmorrhoid with or without bleeding
points at 3,7,11 clock position. Grade I- punctuate bleeding , non protruding. Grade II-
protrudes during straining, reduces spontaneousl. Grade III-protrudes during straining needs
to be manually reduced. Grade IV– prolapsed haemorrhoids. No other diagnostic modality
needed  other than proctoscopy
Investigations
In selected cases of high fistula, multiple fistulae,and recurrent fistulae.
 Fistulography
 Endoanal/endorectal ultrasonography
 MRI
 Barium enema/small bowel series
 Anal m anometry
 Examination under anesthesia
 Proctosigmoidoscopy/colonoscopy
Surgical treatment


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 MRI
 Barium enema/small bowel series
 Anal m anometry
 Examination under anesthesia
 Proctosigmoidoscopy/colonoscopy
Surgical treatment
 Treatment of underlying cause, if any-surgical procedure for eradication of tract
 Fistulotomyand fistulectomy
 Mucosal advancement flap
 Seton placement– the following conditions- complex fistulas (i.e., high transsphincteric,
suprasphincteric, extrasphincteric) or multiplefistulas
 Recurrent fistulas after previous fistulotomy
 Anterior fistulas in female patients
 Poor preoperative sphincter pressures
 Patients with Crohn’s disease or patients who are immunosuppressed
Patient education
 Most patients can be treated in an ambulatory setting with discharge instructions and close


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Patient education
 Most patients can be treated in an ambulatory setting with discharge instructions and close
follow-up care. Sitz baths, analgesics, and stool-bulking agents (eg, bran, psyllium products)
are used in follow-up care. Frequent office visits within the first few weeks help to ensure
proper healing and wound care.
HAEMORRHOIDS
Haemorrhoids(commonly calledpiles)arethedilated tortuousveinsoccurringin relation tothe
anus. These can be primary or secondaryto carcinomaof rectum,pregnancy,strainingat
micturition,orconstipation.C lassifiedintoexternal,internalor mixed(externo-internal).
Salient features


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 Major factors are neuropathy, vasculopathy, infection.
 Minor factors arearch collapse, microcirculatory abnormality, glycosylation of skin
proteins, reduced host immunity, altered  blood viscosity and rheological properties,
associoted renal oedema,hypertension induced vessel thickness,increased weight bearing
due to obesity.
Non pharmacological treatment
 High fiber diet
 Plenty of fluids
 Sitz bath-twice a day with lukewarm water
Pharmacological treatment
 Bulk forming laxative (esabgol husk),at bed time to relieve constipation.
 Local lignocaine 2% ointment if associated external haemorrhoids
Surgical measures
 Grade I-conservative management, injection sclerotherapy for bleeding hemmorrhoids.
 Grade II-conservative management and band ligation.


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 Grade I-conservative management, injection sclerotherapy for bleeding hemmorrhoids.
 Grade II-conservative management and band ligation.
 Grade III/IV– hemorrhoidectomy.
DIABETIC FOOT
It is infection, ulceration and /or gangrene of foot due to diabetes and/or its complication.
Precipitating factors are moisture, trauma-mechanical causes like ill fitting shoes, in growing toe
nail, thorn prick, physical, heat, cold and infection.
Salient features
Clinical classification-Maggit's classifacation
Grade 0-foot symptoms without ulcer
Grade 1-superficial ulcer
Grade 2-deep ulcer
Grade 3-deep ulcer with bone involvement
Grade 4-forefoot gangrene
Grade 5-whole  foot gangrene
Clinicalclassification ofneuropathy
Category 1-no loss of sensation
Category2-loss of sensation


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Grade 5-whole  foot gangrene
Clinicalclassification ofneuropathy
Category 1-no loss of sensation
Category2-loss of sensation
Category 3-loss of sensation with deformity
Category 4-loss of sensation with ulcers


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 Aching in the veins at the end of day, after prolong standing,ankle swelling, itching,
bleeding, superficial thrombophlebitis, eczema, lipodermatosclerosis andulceration.
 Tortuous dilated vein are the in subcutaneous tissue indicative of vericose vein.
Varicocities in the thigh are indicative of long saphenous incompetence, whereas
varicosities of back of leg are suggestive of short saphenous incompetence.
Investigations
Hb, TC ,D C ,Blood sugar-FBS, PPBS, BUN, S. creatinine,urine-sugar/ketone bodies.
LocalX -ray foot, biopsy from the edge off ulcer,pus swab for culture and sensitivity,Doppler to
judge vascularity
Treatment
According to grade
 Grade 0: No specific treatment, take preventive measures to protect the limbs


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judge vascularity
Treatment
According to grade
 Grade 0: No specific treatment, take preventive measures to protect the limbs
 Grade 1: Prescribe  special cushioned shoes to protect from pressure sore
 Grade 2:  control of sugar, antibiotics according to culture reports, daily dressing and
debridement.
 Grade 3: Apart from the management described above , drainage of abscess or local
amputation
 Grade 4: Patientswith forefoot gangrene require amputation
 Grade 5: Amputation and rehabilitation
VARICOSE VEINS
These are defined as tortuous dilated vein. Affect 5% or more of the adult population.
Salientfeatures
Investigations
Brodie Trendelenberg test, tourniquet test,Perthe's test,Perthe's test(modified),Schwartz test,


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Salientfeatures
Investigations
Brodie Trendelenberg test, tourniquet test,Perthe's test,Perthe's test(modified),Schwartz test,
Pratt's test,M orrissey's cough impulse test,Fegan's method to indicate the sites of perforators,
pitting oedema, thickening, redness, tenderness at lower part of leg, lipodermatosclerosis
Non pharmacological treatment
Reassurance, elastic compression stockings- 6” elastic compression stockings applied with
graduated pressure,foot end elevation
Pharmacological treatment
 Injectionsclerotherapy
 Ultrasound guided foam sclerotherapy
Surgical treatment
 Saphenofemoral junction ligation and greater saphenous stripping with or without
incompetent perforator ligation


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 Saphenopopleteal junction ligation and lesser saphenous stripping withor without
incompetent perforator ligation
 Split thickness skin grafting for venous ulcers ,if present
DEEP VENOUS THROMBOSIS
A venous thrombus is the formation of a semisolid coagulum within flowing blood in the venous
system. Venous thrombosis of the deep veins of the leg is complicated by the immediate risk of
pulmonary embolus and sudden death.
Salient features
Risk factors
Patient factor:age, obesity, varicose veins, immobility, pregnancy, puerperium, high dose
oestrogen therapy,previous deepvein thrombosis or pulmonary embolism, thrombophilia
Disease or surgical procedure:trauma or surgery of pelvis , hip or lower limb, malignancy


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Disease or surgical procedure:trauma or surgery of pelvis , hip or lower limb, malignancy
especially pelvic, and abdominal metastatic, heart failure, recent myocardial infarction, paralysis
of lower limbs, infection, inflammatory bowel disease, nephrotic syndrome, polycythemia,
paraproteinemia, homocystinemia
Investigations
D -dimer, PT, APTT, duplex ultrasound
Pharmacological treatment
 Start with low molecular weight heparin anticoagulated with warfarin.
 Warfarin started at a dose of 10 mg on day one,10mg on day 2, 5mg on day three
 Patient taken on day three guides  maintenence dose of warfarin
 Venous thrombectomy in severecases.
 Venacaval filters in recurrent and high risk cases.
Prophylaxis


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 Venous thrombectomy in severecases.
 Venacaval filters in recurrent and high risk cases.
Prophylaxis
M echanicalmethods-graduated elastic compression stockings,external pneumatic compression
stockings.
Low molecular weight heparin
CERVICAL LYMPHADENOPATHY
An enlargedcervicallymph node isthecommones t causeof lump intheneck.Cervical lymph
nodes may become enlargedas a resultof inflammationor neoplasticprocess. Tuberculosisisis
 C hanges in the vessel wall (endothelial damage),stasiswhich is diminished blood flow
throughthe veins, coagulability of blood(thrombophilia).
 Pain and swelling in the calf of one of the lower limb, mild pitting oedema of ankle,
dilated surface veins, stiff calf and redness over the course of the deep veins, Homan's


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dilated surface veins, stiff calf and redness over the course of the deep veins, Homan's
sign; resistance(not pain) of the calf muscle to forcible dorsiflexion, low grade pyrexia.


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 Detailedhistoryand examination areessentialtopinpointspecificetiology.
 Majorityof the lymph nodes are reactiveto viral infectionsof upper respiratorytract,
therefore,do notrequireany treatm ent.
oneofthecommones tcausesofcervicallymphadenopathy(Table 2).
Table 2. Causes and clinical features of cervical lymphadenopathy
Condition Causes Clinicalfeatures
Acute inflammation Infectionof the digestive  tract,head
and neck orother
Fever ,sore throat,
Firm tender 1-2 cm diameter
nodes
Chronic inflammation Tuberculosis,sarcoidosis,
HistiocytosisX
Swelling in the neck, firm,
matted , fever may or may
not  be present
Lymphomas Hodgkins / NonH odgkins
lymphoma
Large painless rubbery
lymph nodes.
Metastatic Carcinomas oftheupper digestive
tract,,skintumours ofthe head and


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lymphoma
Large painless rubbery
lymph nodes.
Metastatic Carcinomas oftheupper digestive
tract,,skintumours ofthe head and
neck:squam ous cellcarcinom a,basal
cellcarcinoma,m elanoma
Symptoms relatedtoprimary
disease,
Salient features
Pharmacological treatment
 In case of acute suppurative lymphadenopathy secondary to any focus of bacterial
infection in thedrainagearea:Cap.cephalexin 250-500 mg every 6 hoursfor7 days or C ap.
amoxicillin250-500 mg every8 hoursfor7 days.
 If lymph nod es persist, perform fine needle aspiration cytology (FNAC) and treat
accordingly.If FNAC is non-conclusivetake a biopsy from the enlargedlymph node and
treataccordingly.
 In case of chroniclymphadenopathyperform FNAC and treataccordingly.IfFN A C is non-
conclusive,performbiopsy and treataccordingly.


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 In case of chroniclymphadenopathyperform FNAC and treataccordingly.IfFN A C is non-
conclusive,performbiopsy and treataccordingly.
Treatment of tubercularlymphhad enopathy
 Startanti-tuberculartherapy
 Reassessthepatientafter6 months.Iflymph nodes areeither notpresentor lessthan 1 cm
size,keep thepatientunderfollow-up and continuetreatment.However, iflymph nodes are
palpableand more than 1 cm ,takea biopsyof the node and treat accordinglyand consider
second line antitubercular drugs.


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 The patient is euthyroid,the nodules are palpable often visible( smooth, firm),painless
and moves with swallowing.
 Tiredness,emotional lability,weight loss,excessive appetite,palpitation,tachycardia, hot
moist palms ,exopthalmos,lid lag/retraction,agitation,thyroid goitre and bruit
THYROID NODULE
 The normal thyroid gland is impalpable. The term goitre is used for generalizedenlargement
of thyroid gland. A discrete swelling in one lobe with no palpable abnormality elsewhere is
termed as isolated or solitary swelling. Discrete swellings with evidence of abnormality
elsewhere in the gland is termed as dominant
 Cause arephysiological, puberty, pregnancy, Grave's disease,  multinodular, toxic adenoma,


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elsewhere in the gland is termed as dominant
 Cause arephysiological, puberty, pregnancy, Grave's disease,  multinodular, toxic adenoma,
neoplastic, benign, malignant, inflammatory,  autoimmune, chronic lymphocytic thyroiditis,
H ashimoto's disease, granulomatous, de Quervain 's thyroiditis, fibrosingR iedel's thyroiditis.
Infective can be acute (bacterial,viral) or chronic(tubercular, syphilitic),other   amyloid
etiologyand iodine deficiency.
Salient features
Investigations
Thyroid function test, autoantibody titre, isotope scan, ultrasonography, FNAC, CT scan, MRI,
PET scan,laryngoscopy andcore biopsy
Prevention and treatment of simple goiter
 Iodised salt
 In hyperplastic goiter,thyroxine 0.15-0.2mg daily for two months


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Prevention and treatment of simple goiter
 Iodised salt
 In hyperplastic goiter,thyroxine 0.15-0.2mg daily for two months
 Multinodular goiter totalor subtotal thyroidectomy. after subtotal resection, thyroxineis
givento suppress TSH secretion
Surgical treatment
 Total thyroidectomy = total lobectomy + isthmusectomy
 Subtotal thyroidectomy = subtotal lobectomy + isthmusectomy
 Near total thyroidectomy = total lobectomy + isthmusectomy + subtotal lobectomy
 Lobectomy = total lobectomy + isthmusectomy
HYPERTHYROIDISM
Salient features
Investigations
Thyroid function test: normal T4, suppressed TSH, thyroid scan
Non pharmacological treatment
Rest and sedation


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 Noncyclical usually of chestwall origin and more common in peri-menopausal women.
 Cyclical mastalgia is common in child bearing age.
 Benign lumpiness may be bilateral present inupper outer quadrant may confined to one
quadrant. Increases before menstrual period.
 Fibroadenoma presents as benign discreet lump
Pharmacologicaltreatment
 Tab. carbimazole  10 mg four times a day, when patient becomes euthyroidand maintenance
dose of 5 mg two or three times a day for 6-24 months
Surgical treatment
 Large toxic multinoduler goiter-total thyroidectomy
 Large diffuse toxic goiter- Promote elective surgery after a course of treatment with
antithyroid drugs and beta blocker. A subtotal thyroidectomyisperformed.


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antithyroid drugs and beta blocker. A subtotal thyroidectomyisperformed.
 Toxic solitary nodular goitre /toxic adenoma/autonomous hot nodule-hemithyroidectomy
 Thyrotoxicosis in pregnancy-subtotal thyroidectomy in mid trimester
 Hashimoto’s disease/lymphedenoid goiter-total thyroidectomy  or total lobectomy
BENIGN BREAST DISEASES
It may be cyclical or noncyclical mastalgia and benign breast lump (fibroadenoma)
Salient features
Investigations
Ultrasound of breast and axilla, mammography for patients above 35 years of age.
FNAC may show fibroadenoma or changes of fibroadenosis.
Non pharmacological treatment
 Reassurance
 Adequate support
 Exclusion of caffeine in some patients
 Evening primrose oil 1000 mg TDS for 3 months


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 Reassurance
 Adequate support
 Exclusion of caffeine in some patients
 Evening primrose oil 1000 mg TDS for 3 months
 If does not respond, Tab.danazol 100 mg OD, can be increased upto TDS after discussing
side effects of the drugs to the patient (hirtuism, contraception failure)
 For fibroadenoma, no treatment is required.Excision is done on patient’s will, suspicious
cytology or large (>5 cm ) lump
BREAST ABSCESS
Usually the abscess is superficial but deep ones, when they occur, are more difficult to diagnose
and to treat.


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 Middle age female, lump in breast and/or axilla, skin changes over breast, nipple
discharge, weight loss.
 Examination of breast as whole with nipple areola complex. Examination of axillaas well
as theopposite breast and axilla.
Pharmacological treatment
Early in the infection, non-surgical measures should be applied
 Tab. amoxicillin (PO) : 1-2 gm/ d divided in 2-3 doses  for 5 days or
 Cap. ampicillin (PO) : 2-4 gm/ d divided in 2-3 doses  for 5 days
 Tab. ibuprofen 400 mg thrice daily.
Non pharmacological treatment
 Apply constricting bandage, stop breast-feeding from this side
 Expression of milk with a breast pump to avoid engorgement.
Surgicaltreatment
 For superficial abscess: radial incision.
 For abscess near nipple: peri-alveolar incision.


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Surgicaltreatment
 For superficial abscess: radial incision.
 For abscess near nipple: peri-alveolar incision.
 For deep abscess: beneath the breast
 Gentle exploration with finger or Kelly forceps. Abundant lavage with chlorhexidine-
cetrimide solution. Insertion of a corrugated drain.
CARCINOMA BREAST
Carcinoma of breast is most common malignancy in female population world wide and second
most common in India.
Salient features
Investigations
Mammography, look for the non palpable lesion in same breast as well as base line investigation
in opposite breast.FNAC ,true cut biopsy,excisional biopsy ifmass < 4 cm in size,incisional
biopsy ifmass > 4 cm size
Surgical treatment
 Modified radicalm astectomy is removal of whole breast tissue with nipple areola complex,


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biopsy ifmass > 4 cm size
Surgical treatment
 Modified radicalm astectomy is removal of whole breast tissue with nipple areola complex,
skin overlying lump, pectoral fascia and axillary dissection.
 For Stage II B, Stage III A:  Breastconservative surgery along with radiotherapy
 Lumpectomy/quadrentectomy/wide excision isindicated in solitary lump, tumor size < 4 cm,
not involving nipple areola complex
 DCIS for Stage I, Stage II A


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Pharmacological treatment
 Neo adjuvant chemotherapy: Adjuvant chemotherapy given beforesurgery for down staging
of locally advanced breast cancer, Stage III B
 Adjuvant chemotherapy:  Post operative chemotherapy for
- all node positive cancers
- node negative cancer, > 1 cm in size
- node negative cancer, > 0.5 cm with adverse prognostic factors
- (lymphovascular invasion, high nuclear grade, high histological grade, HER 2/neu over
expression, negative hormone receptor status)
 Commonly used regimen for chemotherapy are-
- CMF regimen: cyclophosphamide, methotrexate, 5-fluorouracil- 6 cycle, every 21days
- CAF regimen: cyclophosphamide, adriamycin, 5- Fluorouracil 6 cycle, every 21 days
- Cyclophosphamide: 600 mg/ sqm body area IV
- 5 Fluorouracil: 600 mg/sqm body area IV


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- Cyclophosphamide: 600 mg/ sqm body area IV
- 5 Fluorouracil: 600 mg/sqm body area IV
- Methotrexate: 40 mg/sqm body area IV
- Adriamycin: 50 mg/sqm body area IV
Hormonal regimen
Tab. tamoxifen 20 mg orally daily, 5 years given to ER/PR positive patients.
RENAL STONES
Renal stones are common in India and are caused because oflow fluid intake, high salt
concentrate in water. Vitamin A deficiency, renal infections, inadequateurinary drainage and
urinary stasis,prolonged immobilization, hyperparathyroidism are also the common causes.
Types of stone: Oxalate stones, phosphate stones,uric acid stones (radiolucent stones), cystine
stones,xanthine stones
Salient features
Investigations
X ray KUB,ultrasonographyof KUB ,intravenous urography,CT -IVP
Pharmacological treatment


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stones,xanthine stones
Salient features
Investigations
X ray KUB,ultrasonographyof KUB ,intravenous urography,CT -IVP
Pharmacological treatment
 Inj. diclofenac sodium 3 ml IM stat
 Inj. dicyclomine 2 ml IM stat
 Tab. ciprofloxacin 500 mg BD for 5 days
 Salientcalculus, colicky pain in lumbar region of the affected side, worsened by
movements. hematuria, burning micturition.
 Rigidity of lateral abdominal muscles but not the rectus abdominis.Tenderness in lumbar
region


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 It is also be caused by neurogenic bladder (commonly pelvic splanchic nerve damage,
cauda equina syndrome, descending cortical fibers lesion, pontine micturation or storage
center lesions) orcan be iatrogenicin nature(caused by medical treatment/procedure),
scarring of the bladder neck (commonly from removal of indwelling catheters or
cystoscopy operations)ordamage to the bladder
 In the prostate the causes may be BPH, prostate cancerand other pelvic malignancies,
prostatitis.
 In urethra- congenital urethral valves, phimosis or pinhole meatus, obstruction in the
urethra, for example a stricture (usually caused either by injury or STD), a metastasis or a
precipitated pseudo gout crystal in the urine


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urethra, for example a stricture (usually caused either by injury or STD), a metastasis or a
precipitated pseudo gout crystal in the urine
 STD lesions (gonorrhoea causes numerous strictures, leading to a "rosary bead"
appearance, whereas chlamydia usually causes a single stricture)
 Inability to pass urine, thinningof urinary stream, dribbling of urine, pain in infraumbilical
regionor palpable urinary bladder above pubic symphysisis seen.
 Potassium citrate 5 ml in 100 ml of water 3-4 times/day
 Calculi less than 5 mm can pass spontaneously and require no surgical intervention
Non pharmacological treatment
High fluid intake is advised with avoidance of lithogenic food and beverages
Surgical treatment
Kidney stones
 Percutaneus nephrolithotomy (PCNL)


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High fluid intake is advised with avoidance of lithogenic food and beverages
Surgical treatment
Kidney stones
 Percutaneus nephrolithotomy (PCNL)
 Extracorporeal shockwave lithotripsy (ESWL)
 Open pyelolithotomy
 Nephrolithotomy
Ureteric stones
 Endoscopic removal by uretero renoscopy, dormia basket, ureteric meaotomy or open
ureterolithotomy
URINARY RETENTION
Urinary retention, also known as ischuria, is a lack of ability to urinate. It is a common
complication of BPH-Benign Prostatic Hyperplasia.
Salient features
Treatment
 Insertion of a low diameter (10 to 12 French) urinary catheter or
 Insertion of Infant Feeding Tube (IFT, 5to 7 French diameter) or
 Suprapubic catheterisation (SPC)


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 Symptoms of acute lower respiratory tract illness (cough with or without
expectoration, shortness of breath, pleuritic chest pain) for less than 1 week
 Temperature >37.7ºC, chills withrigors, and/or severe malaise
 Chest signs- bronchial breath sounds and/or crackles); withno other explanation for
the illness.
Chapter 17
RESPIRATORY DISEASES
COMMUNITY ACQUIRED PNEUMONIA
Community acquired pneumonia (CAP) can be defined as inflammation of lung parenchyma
due to infection byStreptococcus pneumoniafollowed byStaphylococcus aureus,Klebsiella
pneumoniae and Haemophilus influenzae.Atypical organisms includeMycoplasma,
Chlamydia and certain respiratory viruses.
Salient features
Investigations
 Chest X ray in all patients suspected with CAP.Itshould be repeated if the patient is not


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Salient features
Investigations
 Chest X ray in all patients suspected with CAP.Itshould be repeated if the patient is not
improvingorhavingpersistence or worsening of symptoms/physical signs.
 Centrilobularnodules favore non-bacterial pneumonia, while airspace nodules are
common with bacterial pneumonia.
 CT of the chest should be performed in those with non-resolving pneumonia and for the
assessment of complications of CAP.
 Legionella urinary antigen test isdesirable in patients with severe CAP.
Pharmacological treatment
Initial empirical antibiotic therapy may be useful in severe disease, co-morbid conditions like
chronic heart, lung or renal diseases, diabetes mellitus, malignancies andimmune -


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chronic heart, lung or renal diseases, diabetes mellitus, malignancies andimmune -
compromised conditions.The antibiotic can then be modified as per the response and sputum
culture. The choice of the empirical antibiotic,
Outpatients
 Previously healthy and no antibiotics in past 3 months
A macrolide [clarithromycin (500 mg orally BD) or azithromycin (500 mg orally once,
then 250 mg qd)] ordoxycycline (100 mg orally BD) for 7 to 14 days
 Co -morbidities or antibiotics in past 3 months: select an alternative from a different class
Co -morbidities like alcohol consumption, leucopenia, congestive heart failure, coronary
artery disease, diabetes mellitus,immune -compromised state and increasing age.
Fluoroquinolones [levofloxacin (750 mg orally OD) or moxifloxacin (400 mg orally OD)]


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Fluoroquinolones [levofloxacin (750 mg orally OD) or moxifloxacin (400 mg orally OD)]
for 10 to 14 days or
beta-lactams [high-dose amoxicillin (1 g TDS) oramoxicillin/clavulanate (2 g TDS);


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 Alternatives: ceftriaxone (1–2 g IV OD), cefpodoxime (200 mg orally BD), cefuroxime
(500 mg orally BD)]plusmacrolide [clarithromycin (500 mg orally BD) or azithromycin
(500 mg orally once, then 250 mg OD)] for10 to 14 days
Inpatients, Non-ICU
 A respiratory fluoroquinolone [levofloxacin (750 mg oral or IV OD), moxifloxacin (400
mg oral or IV OD)] for 10 to 14 days
 Alternatively beta-lactams [cefotaxime (1–2 g IV TDS), ceftriaxone (1–2 g IV OD),
ampicillin (1–2 g IV every 4–6 hourly), ertapenem (1 g IV OD in selected patients)]plus
macrolide [oral clarithromycin or azithromycin (as listed above for previously healthy
patients) or IV azithromycin (1gm once then 500 mg daily)]– parentally for 5 to 7 days
and then after orally for 10 days
Inpatients, ICU


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patients) or IV azithromycin (1gm once then 500 mg daily)]– parentally for 5 to 7 days
and then after orally for 10 days
Inpatients, ICU
 Beta-lactams [cefotaxime (1–2 g IV TDS), ceftriaxone (2 g IV OD), ampicillin-sulbactam
(2 g IV TDS)] for 5 to 7 daysplusazithromycin or fluoroquinolone (as listed above for
inpatients, non-ICU) for 5 to 7 days and to continue after discharge oral medication for 10
days
Specialconcerns
 IfPseudomonas is a considered,
An antipseudomonal beta-lactam [piperacillin/tazobactam (4.5 g IV QID), cefepime (1–2
g IV BD), imipenem (500 mg IV QID), meropenem (1 g IV TDS)] plus either
ciprofloxacin (400 mg IV BD) or levofloxacin (750 mg IV OD) or aminoglycoside
[amikacin (15 mg/kg OD) or tobramycin (1.7 mg/kg OD)]


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ciprofloxacin (400 mg IV BD) or levofloxacin (750 mg IV OD) or aminoglycoside
[amikacin (15 mg/kg OD) or tobramycin (1.7 mg/kg OD)]
 If CA -MRSA (methicillin resistantStaphylococcus aureus) is a considered- Add
linezolid (600 mg IV BD) or vancomycin (1 g IV BD).Total duration in above situations
is 14 days including IV for 5 days and oral medication for remaining period.
Recommendations for use of steroids in CAP- They shouldbe used in septicshock or
ARDS secondary to CAP.
Monitoring
- Antimicrobial therapy should be changed according to the specific pathogen(s)
isolated.
- Diagnostic/therapeutic interventions should be done for complications e.g.
thoracocentesis, chesttube drainage, etc asrequired.
- If a patient does not respond to treatment within 48-72 hours, he/she should be


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thoracocentesis, chesttube drainage, etc asrequired.
- If a patient does not respond to treatment within 48-72 hours, he/she should be
evaluated for the cause of non-response including development of complications,
presence of atypical pathogens, drug resistance, etc.
- Non - invasive ventilation should be used in patients with CAP and acute respiratory
failure.


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New or progressive radiological deterioration along with any two below
 New onset of fever, purulent discharge, leukocytosis and decline in oxygenation,purulent
sputum, orincreased respiratory secretions, dyspnea or tachypnoea
 Altered mental status
 Patients withAcute respiartory distress syndrome (ARDS ) as harboring VAP if sustained
increase in PEEP requirement >2.5 cm H2O after being stable or decreasing orFraction of
inspiredoxygen (Fio2)  requirementrise by > 0.15after being stable or decreasing.
 H igh risk for developing HAP/VAP e.g. chronic cardiovascular, pulmonary, renal or liver
disease, diabetes mellitus, CSF leak, asplenia, immunocompromised condition/medication,
influenza, compromised respiratory function or increased aspiration risk.


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influenza, compromised respiratory function or increased aspiration risk.
 B lood should be sent for culture prior to antibiotics. However, appropriate management
should not be delayed in clinically unstable patients for purpose of performing diagnostic
sampling.
Follow up
 Switch to oral from IV therapy if the patient shows improvement in moderate to severe
CAP.
 Patient can be considered for discharge after they start accepting drugs orally, are
afebrile, and hemodynamically stable for a period of at least 48 hr
HOSPITAL ACQUIRED PNEUMONIA
Hospital Acquired Pneumonia (HAP)is an inflammatory condition of lung parenchyma
caused by infectious agents, neither present nor incubating at time of hospital admission. It is


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caused by infectious agents, neither present nor incubating at time of hospital admission. It is
defined as pneumonia developing 48 h after admission to the hospital. It can be caused by a
wide range of pathogensincluding gram negative bacilli such asP.aeruginosa, E.coli,
K.pneumoniae and Acinobacter. Ventilator Associated Pneumonia (VAP) is defined as
pneumonia (new onset of fever) thatdevelops after 48 hour of endotracheal intubation.
Salient features
Pharmacologicaltreatment
Risk factors for pneumonia: Age >60 years, male gender, smoking, alcohol intake,
underling disease, inspired O2 >0.50, renal failure/dialysis, chronic obstructive pulmonary
disease, airway instrumentation, aspiration before intubation, tracheostomy, mechanical


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disease, airway instrumentation, aspiration before intubation, tracheostomy, mechanical
ventilation >2 days, coma, head trauma, continuous enteral feeding, prior antibiotics,
nosocomial maxillary sinusitis, repeat intensive care unit admission
Patients withoutriskfactors for MDR pathogens(Treatment duration is 10 to 14 days)
ceftriaxone (2 g IV OD)or moxifloxacin (400 mg IV OD), ciprofloxacin (400 mg IV TDS),
or levofloxacin (750 mg IVOD) or ampicillin/sulbactam (3 g IV QID)
Patients withriskfactors for MDR Pathogens(Treatment duration is 10 to 14 days)


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351
1. Beta-lactams: ceftazidime (2 g IV TDS) or cefepime (2 g IV BD/TDS) or
piperacillin/tazobactam (4.5 g IV QID), imipenem (500 mg IV QID or 1 g IV TDS), or
meropenem (1 g IV TDS)plus
2. A second agent active against gram-negative bacteria pathogens:gentamicin or
tobramycin (7 mg/kg IV OD) or amikacin (20 mg/kg IV OD)orciprofloxacin (400 mg IV
TDS) or levofloxacin (750 mg IV OD)plus
3. An agent active against gram-positive bacteria pathogens:linezolid (600 mg IV BD)or
vancomycin (15 mg/kg, up to 1 g IV, BD)
Follow up
 Clinical improvementusually evident within 48–72 h of the initiation of antimicrobial
treatment. Because findings on chestradiography often worsen initially during treatment,


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treatment. Because findings on chestradiography often worsen initially during treatment,
they are less helpful than clinical criteria as an indicator of clinical response in severe
pneumonia.
 Seriously ill patients with pneumonia, often undergo follow-up chest radiography daily, at
least until they are being weaned off mechanical ventilation. Once a patient has been
extubated and is in stable condition, follow-up radiographs may not be necessary for a
few weeks
Patient education (to reduce the frequency of nosocomial pneumonia in mechanically
ventilated patients)
 General methods:Aggressive treatment of patient’s underlying disease, Review need and
avoid antacids and H2 blockers for stress ulcer prophylaxis, keep patient elevated at≥ 30º,


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avoid antacids and H2 blockers for stress ulcer prophylaxis, keep patient elevated at≥ 30º,
review nutrition regimen and tube feeding procedures, extubate and remove nasogastric
tube as clinically indicated, controlled use of antibiotics.
 Respiratory care equipment: Discriminate between equipment with nebulizers and
humidiﬁers ≥48-h circuit changes (tubing and humidiﬁer) for mechanical ventilators with
humidiﬁers; no changes for circuits with heat -moisture exchangers, proper removal of
respiratory tubing condensate and education of staff to prevent washing contaminated
condensate into the patient’s trachea, no transfer of equipment or devices between
patients, review use and care of in-line medication nebulizers.


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condensate into the patient’s trachea, no transfer of equipment or devices between
patients, review use and care of in-line medication nebulizers.
 Infection control: Surveillance in the ICUeducation and awareness programs on
nosocomial infection, handwashing and/or barrier precautions, review technique for
suctioning patients; type of catheter used, review method of condensate disposal, use
effective methods of disinfection of devices and equipment, consider selective
decontamination of the digestive tract with oral nonabsorbable antibiotics to prevent
nosocomial infection.
BRONCHIAL ASTHMA
Asthma is a chronic inflammatory disorder of the airways characterized by episode of
wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early


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352
 Precipitating allergens are dust, pollen, fish, nuts, strawberries, cold air, tobacco smoke,
viral and bacterial infections, exercise, emotional stress and drugs like NSAIDs, aspirin,
beta-blocker
 Classical symptoms include cough, breathlessness, chest tightness and wheezing. Signs
include tachypnoea, tachycardia, pulsus paradoxus, use of accessory muscles, silent chest
morning. It is associated with widespread but variable airflow obstruction that is often
reversible either spontaneously or with treatment.
Salient features
Diagnosis
 When asthma is suspected and other disorders have been ruled out (e.g. tumours in adults,
foreignbody in children; don’t assume the presence of wheeze means asthma), confirm
the diagnosis with pulmonary function tests (PFTs).


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foreignbody in children; don’t assume the presence of wheeze means asthma), confirm
the diagnosis with pulmonary function tests (PFTs).
 PFTs suffice as objective evidence of variable airflow obstruction:
- A 12 % or greater improvement in forced expiratory volume (FEV1) in children and
adults, and > 200 ml in adults from the baseline 15 minutes after use of an inhaled
short-acting beta2 agonist.
- Serial measures of peak expiratory flow (PEF): A > 20% change after administration
of a bronchodilator.
 When there is some probability of asthma and the above tests are non-diagnostic, the
following tests may be used to help diagnosis of asthma:
- Methacholine challenge
- Exercise challenge
- Inhaled corticosteroid trial: appropriate doses of inhaled steroids for 4-6 weeks


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- Methacholine challenge
- Exercise challenge
- Inhaled corticosteroid trial: appropriate doses of inhaled steroids for 4-6 weeks
- Raised value of absolute eosinophil count (>6-8%)
Non pharmacologicaltreatment
 Evaluate and assess impact and exposure to allergens and irritants in individual patients.
 Complete cessation of smoking and avoidance of environmental tobacco smoke is
strongly recommended.
 Lifestyle management-refer patients to an asthma education program where available.
Pharmacological treatment
 If expiratory flows are normal and symptoms are controlled, an inhaled short-acting beta2
agonistas needed.
 If rescue beta2 agonist is needed more than 2 times per week (excluding preventative use


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agonistas needed.
 If rescue beta2 agonist is needed more than 2 times per week (excluding preventative use
prior to exercise) or if lung function is abnormal, an inhaled glucocorticosteroidused.
 Use of spacer:Technically, the most efficient way to maximize inhaled drug delivery to
the lungs is through a metered dose inhaler (MDI) and spacing device. For adults,
however, a dry powdered inhaler (DPI) has demonstrated efficacy and is more convenient


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353
for most people. If using an inhaled corticosteroid MDI, a spacer device, in addition to
usual oral hygiene, will minimize the risk of oral thrush.
Step wise control of chronic asthma in patients more than 6 years of age(Table 1)
 Patient should start treatment at the step most appropriate to the initial severity of their
asthma.
 At each step, review medication adherence, inhaler technique, and patient education.
Reconsider diagnosis if no or poor response to therapy.
 If symptom control is maintained over 3 months, consider stepping down to the least
medication necessary to maintain control.
Tab le 1. Step wise control of chronic asthma in patients more than 6 years of age
Step 1 Inhaled short-acting beta2 agonist (SABA) as required.


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Tab le 1. Step wise control of chronic asthma in patients more than 6 years of age
Step 1 Inhaled short-acting beta2 agonist (SABA) as required.
Step 2 Add inhaled corticosteroid (ICS). In children age 6-11 years, start at a low dose.
Step 3
Add inhaled long-acting beta2 agonist (LABA) in combination with an ICS.
Assess control of asthma:
 Good response to LABA/ICS combination➞ continue
 Benefit from LABA/ICS combination but control still inadequate➞ continue
LABA and increase steroid dose to high dose ICS
 No response to LABA/ICS combination➞ stop LABA combination and
continue high dose inhaled steroid and proceed to Step 4
Step 4
Consider the following:
 A short course of oral corticosteroids may be used in adults (i.e. prednisone
0.6 mg/kg/day for 5 days) to stabilize the patient


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 A short course of oral corticosteroids may be used in adults (i.e. prednisone
0.6 mg/kg/day for 5 days) to stabilize the patient
 Referring patient for specialist care
 Adding a third drug (e.g. leukotriene receptor antagonist, theophylline, or low
dose daily oral steroids)
Table 2 showing control of asthma
Characteristic
Controlled
(all of the
following)
Partly controlled
(any measure
present in any week)
Uncontrolled
Daytime symptom None
(twice or less/wk)
More than
twice/week
Three or more
feature of
partly
controlled
asthma present
in any week
Limitation of activities None Any
Nocturnalsymptom
/awakening None Any
Need for reliever/rescue
treatment
None
(twice or less/wk)
More than
twice/week
Lung function
(PEF of FEV1)* Normal
< 80% predicted or
personal best (if
known)


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treatment
None
(twice or less/wk)
More than
twice/week
Lung function
(PEF of FEV1)* Normal
< 80% predicted or
personal best (if
known)
Exacerbation None One or more/year † One in any
week‡
* Lungfunction testing is not reliable for children 5 years and younger.


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† Any exacerbation should prompt review of maintenance treatment to ensure that it is
adequate.
‡ By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Table 3. Drugs and recommended dosage
Drugs
Adult (mcg per day) Children (6-11 years)mcg per
day
Low Medium High (Max) Low Medium High (Max)
Beclomethasone
dipropionate pMDI ≤ 250 251-500 > 500 (800) ≤ 100 101-200b > 200 (200)
Budesonide DPI ≤ 400 401-800 > 800 (2400) ≤ 200 201-400b > 400 (400)
Ciclesonide pMDI ≤ 200 201-400 > 400 (800) 100 101-200b > 200 (200)
Fluticasone
priopionate  pMDI ≤ 250 251-500 > 500 (2000) ≤ 100 101-200b > 200 (400)
Fluticasone
PriopionateDPI ≤ 250 251-500 > 500 (2000) ≤ 100 101-200b > 200 (400)
Follow up


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Fluticasone
PriopionateDPI ≤ 250 251-500 > 500 (2000) ≤ 100 101-200b > 200 (400)
Follow up
 A n action plan to increase therapy when asthma is not controlled and to decrease therapy
when asthma is well controlled
 Periodically discuss adequacy of asthma control with the patient. Identify and eliminate
barriers to effective control.
 Consider measuring peak flow at each visit.
 Encourage the patient/family to actively manage their illness.
 If a patient is not responding to therapy, and compliance and inhaler technique is
appropriate, consider an alternative diagnosisand/or referral for further assessment. .
Patient education
 Proper use ofprescribed medication, techniques of administration, what constitutes


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Patient education
 Proper use ofprescribed medication, techniques of administration, what constitutes
“control” of asthma and how to monitor control with PEF measurement or symptom
monitoring.
 Discuss strategies to assist patients to stop smokingand refer patients to smoking
cessation programs.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic Obstructive Pulmonary Disease (COPD) is defined as “A preventable and treatable
disease characterized by persistent airflowlimitation that is not fully reversible. The airflow
limitation is usually progressive and associated with an abnormal inflammatory response of


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355
 Chronic cough, which may be daily and productive, but can also be intermittent and
unproductive.Breathlessness on exertion, initially intermittent and becoming persistent
 Sputum production: any pattern of sputum production may indicate COPD.Frequent
exacerbations of bronchitis
 A history of exposure to risk factors, especially tobacco smoke, occupational dusts,
home cooking and biomass fuels.
the lung to noxious particles or gases with some significant extra pulmonary effects that may
contribute to theseverity in the individual patient”.
Salient features
Diagnosis
Diagnosis is made by spirometry and severity classified as per GOLD (Guidelinesfor
Obstructive Lung Diseases) criteria(Table 4).
Table 4. GOLD criteria for severity of COPD
GOLD


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Obstructive Lung Diseases) criteria(Table 4).
Table 4. GOLD criteria for severity of COPD
GOLD
Stage Severity Symptoms Spirometry
0 At Risk Chronic cough, sputum
production Normal
I Mild With or without chronic
cough or sputum production
FEV1/FVC <0.7 and FEV1 80%
predicted
IIA Moderate With or without chronic
cough or sputum production
FEV1/FVC <0.7 and 50% FEV1 <80%
predicted
III Severe With or without chronic
cough or sputum production
FEV1/FVC <0.7 and 30% FEV1 <50%
predicted
IV Very
Severe
With or without chronic
cough or sputum production
FEV1/FVC <0.7 and FEV1 <30%
predictedor
FEV1 <50% predicted with respiratory
failure or signs of right heart failure
Non pharmacological treatment
 General Medical Care- Patients with COPD should receive the influenza vaccine


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failure or signs of right heart failure
Non pharmacological treatment
 General Medical Care- Patients with COPD should receive the influenza vaccine
annually. Polyvalent pneumococcal vaccine is also recommended, although proof of
efficacyis not definitive.
 Pulmonary Rehabilitation-This refers to a treatment program that incorporates education
and cardiovascular conditioning. In COPD, pulmonary rehabilitation has been
demonstrated to improve health-related quality of life, dyspnea, andexercise capacityand
reduce rates of hospitalization over a 6-to 12-month period.
 Lung Volume Reduction Surgery (LVRS) offers both a mortality benefit and a
symptomatic benefit in certain patients with emphysema. Patients with upper lobe–


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predominant emphysema and a low post rehabilitation exercise capacity are most likely to
benefit from LVRS.
 Lung Transplantation- COPD is currently the second leading indication for lung
transplantation Current recommendations are that candidates for lung transplantation
should be <65 years; have severe disability despite maximal medical therapy; and be free
of co-morbid conditions such as liver, renal, or cardiac disease.
Pharmacological treatment(Table 5)
 Bronchodilators-U sed for symptomatic benefit in patients withCOPD. The inhaled route
is preferred for medication delivery as the incidence of side effects is lower than that seen
with the use of parenteral medication delivery.


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is preferred for medication delivery as the incidence of side effects is lower than that seen
with the use of parenteral medication delivery.
 Theophyllineproduces modest improvements in expiratory flow rates and vital capacity
and a slight improvement in arterial oxygen and carbon dioxide levels in patients with
moderate to severe COPD. Nausea is a common side effect; tachycardia and tremor have
also been reported. Monitoring of blood theophylline levels is typically required to
m inimize toxicity.
 Supplemental oxygen is the only pharmacologic therapy demonstrated to unequivocally
decrease mortality rates in patients with COPD. Patients with resting hypoxemia (resting
O 2 saturation 88% or <90% with signs of pulmonary hypertension orright heart failure)


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O 2 saturation 88% or <90% with signs of pulmonary hypertension orright heart failure)
require continual oxygen supplementation. Various delivery systems are available,
including portable systems that patients may carry to allow mobility outside the home.
Supplemental O2 are commonly prescribed for patients with exertional hypoxemia or
nocturnal hypoxemia.
 Glucocorticoids are not routinely recommended.
 Other agents that can be used as follows: N-acetyl cysteine 600 mg TDS for 10 to 14 days
Table 5. Commonly used drugs and dosages for pharmacotherapy of stable COPD
Drug category Recommended dose
Inhaled agents *
 Anti-cholinergics
-Short actingIpratropium bromide 20-40 µg as needed
-Long actingTiotropium 18 µg once daily
 Beta-agonists
-Short acting Salbutamol 100-200 µg as needed


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-Long actingTiotropium 18 µg once daily
 Beta-agonists
-Short acting Salbutamol 100-200 µg as needed
Levosalbutamol 45-90 µg as needed
Terbutaline 250-500 µg as needed
-Long acting Salmeterol 25-50 µg twice daily
Formoterol 6-12 µg twice daily
Indaceterol 150-300 µg once daily


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 Corticosteroids
-Fluticasone 25-500 µg twice daily
-Budesonide 100-400 µgtwice daily
-Beclomethasone 100-400 µg twice daily
-Ciclesonide 80-160 µg twice daily
-Mometasone 25-500 µg twice daily
Oral agents
 Beta-agonists
-Salbutamol 2-4 mg twice/thrice daily
-Bambuterol 10-20 mg once daily
-Terbutaline 2.5-5 mg TDS
 Methylxanthines
-Sustained release theophylline 100-400 mg once daily
-Doxophylline 400 mg twice/thrice daily
* Recommended doses are those for aMDI. These drugs are also available in DPI and for
nebulizer use, for which doses may vary.
 Only three interventions—smoking cessation, oxygen therapy in chronically hypoxemic
patients, and lung volume reduction surgery in selected patients with emphysema—have


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patients, and lung volume reduction surgery in selected patients with emphysema—have
been demonstrated to influence the natural history of patients with COPD.
 All othertherapies are directed at improving symptoms and decreasing the frequency and
severity of exacerbations. The institution of these therapies should involve an assessment
of symptoms, potential risks, costs, and benefits of therapy.
Acute exacerbation of COPD (Table 6)
 An exacerbation of COPD is an acute event characterized by a sustained worsening of
any of the patient’s respiratory symptoms (cough, sputum quantity and/or character,
dyspnea) that is beyond normal day-to-day variation and leads to a change in medication,
and where other causes of acute breathlessness have been clinically excluded.


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and where other causes of acute breathlessness have been clinically excluded.
Table 6. Severity assessment (indications for hospitalization) of exacerbation of COPD
Symptoms
 Marked reduction in activity of daily living due to dyspnea
 Altered sensorium
 New onset cyanosis
Signs
 Use of accessory respiratory muscles
 Paradoxical chest wall movements
 Central cyanosis
 Systolic blood pressure <90 mmHg


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 RR >30/minute
 Heart rate >110/minute
 Asterixis
 Altered mental status
Others
 Presence ofsevere comorbid conditions
 Lack of social support
Pulse oximetry
 SpO 2<90%
* Presence of any of these qualifies a patient with need for admission. The ultimate decision
to admit depends on the overall clinical assessment of the physician
Treatment of acute exacerbations
Pharmacological treatment
- Bronchodilators
- Corticosteroids
- Antibiotics:  First line (Tab. amoxicillin 500-1000 mg TDS or Cap. doxycycline 100
mg BD or Tab.azithromycin 500 mg OD);  Second line: Tab. amoxicillin/clavulanic
acid (625 mgTDS) or second-generation or third-generation cephalosporin (e.g. Tab.
cefixime 200 mg BD)All antibiotics need to be administered for 5-7 days except


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cefixime 200 mg BD)All antibiotics need to be administered for 5-7 days except
azithromycin (three days)
- Adjunct therapies
 Non -pharmacological treatment
- Oxygen therapy
- Ventilatorysupport (Noninvasive and invasive ventilation)(Table 7and 8)
Table 7:Indications, protocol and parameters of failure of non invasive ventilation in
acute exacerbation of COPD
Indications
 Respiratory acidosis (arterial pH≤ 7.35 and/or PaCO2 45 mmHg)
 Severe dyspnea
 Respiratory rate > 30 breaths/ min
 Use of accessory muscles of respiration
 Presence of paradoxical breathing
Protocol
 Full face mask better tolerated in the acute setting
 Start with an inspiratory pressure support of 6-8 cm H2O and CPAP of3-4 cm H2O
 Adjustments


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-Increase inspiratory pressure and CPAP by 2 and 1 cm H2O respectively
- Titrate to tidal volume (>5 ml/kg), respiratory rate (<35 breaths/minute) and blood
gases
- Maximum inspiratory pressure and CPAP generally used is 15-16 cm H2O and 7-8
cm H 2O respectively
 Air leaks should be minimized
Parameters for failure of NIV
 Failure in improvement of clinical parameters and gas exchange at 1 hour
 Development of alteration in sensorium
 Hemodynamic instability
 Inability to tolerate oronasal mask
Table 8. Indications and protocol of invasive mechanical ventilation#
Indications
 pH ≤7.25
 Unable to tolerate NIV/or NIV failure
 Respiratory or cardiac arrest
 Massive aspiration
 Diminished consciousness
 Failure to handle secretions


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 Respiratory or cardiac arrest
 Massive aspiration
 Diminished consciousness
 Failure to handle secretions
 Heart rate <50/minute with loss of alertness
 Hemodynamic instability without fluid responsiveness
 Severe ventricular arrhythmias
 Life threatening hypoxia
Protocol
Mode V -ACMV
Initial tidal volumes 4-6 ml/kg
Respiratory rate 8-12/min
PEEP 5-8 cm H2O
I:E 1:3-1:6
Flow waveform Square waveform
Goals
Plateau pressure 30 cm H2O
PaO 2 55-60 mm Hg
pH 7.2-7.4
#Modified from GOLD 2013


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 A preponderance of bronchiectasis on the left side and in the lower lobes has been noted.
 Bronchiectasis is classified based on the pathological changes into:follicular, saccular and
atelectatic types.
 Patient usually presents with persistent cough productive of distressingly copious volumes of
mucopurulent and sometimes fetid sputum, in a breathless and chronically disabled patient.
 Mild cases of bronchiectasis often have no abnormal physical signs. When the disease is
sufficiently developed, the characteristicﬁnding is persistent early and mid-inspiratory
crackles which are localized to one or more areas so that they are heard at the same site or
sites on repeated examination. These crackles are frequently described as ‘coarse’ (as


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sites on repeated examination. These crackles are frequently described as ‘coarse’ (as
opposed to ‘ﬁne’) and are not shifted by coughing.
 Clubbing of theﬁngers and/or toes is a feature of gross disease with prolonged bronchial
infection.There may also be cyanosis, with signs of pulmonary hypertension and right heart
failure in such patients.
Criteria for hospital discharge (Modified from GOLD 2013)
 Able to use long acting bronchodilators.Inhaled short acting drugs no more than every 4
hours
 Patient if previously ambulatory-able to move across room,to eat and get adequate sleep
 Patient is clinically stable for at least 24 hours
Follow up
 Motivation to quit smoking
 Assessment of inhaler technique
 Measurement of FEV1
 Compliance with recommended treatment regimen


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Follow up
 Motivation to quit smoking
 Assessment of inhaler technique
 Measurement of FEV1
 Compliance with recommended treatment regimen
 Reassessing the need for long-term oxygen therapy and/or home nebulizer
 Status of co-morbidities
BRONCHIECTASIS
B ronchiectasis is present when one or more bronchi are abnormally and permanently dilated.
Salient features
Diagnosis
 C linical featurewith radiological presentation of plain x-ray chestand a very specific
High resolution computed tomography(HRCT) thorax pattern.
 Plain chest radiographic features include evidence of dilated bronchi, parallel “tramlines”,
solid tubular opacities, appearances of pulmonary hypertension.
 HRCT has become theinvestigation of choice in bronchiectasis (Table 9).


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Table 9. HRCT findings in bronchiectesis
Direct signs Indirect signs
Bronchial dilatation
Increased bronchoarterial ratio,
contour abnormalities
Bronchial wall thickening
Best assessed visually on images obtained at right
angles through vertically oriented airways
Lack of airway tapering >2 cm
distal topoint of bifurcation
Mucoid impaction/fluid-filled airways
Tubular or Y-shaped structures; branching or rounded
opacities in cross section +/-air-fluid levels
Airway visibility within 1 cm of
thecostalpleura of fissures
Bronchiolitis, clustered ill-defined centrilobular nodules
with a tree-in-bud configuration
Mosaic attenuation caused by air trapping–Best identified
on expiratory HRCT images
Mosaic perfusion of the pulmonary identified on contrast-


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Mosaic attenuation caused by air trapping–Best identified
on expiratory HRCT images
Mosaic perfusion of the pulmonary identified on contrast-
enhanced dual energy CT of the pulmonary parenchyma
Bronchial artery hyperplasia
Pharmacological treatment(Table 10)
The treatment of bronchiectasis may be medical or surgical. Medical treatmentaims to
relieve and control the symptoms, whereas surgical treatment is intended to eliminate the
disease itself.The main arms of medical treatment are control of lower respiratory tract
infection/inﬂammation with appropriate antibiotic treatment and the removal of bronchial
secretions by postural drainage
Table 10. Antibacterial agents for the treatment of bronchiectesis
Route Antibiotics Dose and duration
Oral Amoxicillin/clavulanic
acid


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Table 10. Antibacterial agents for the treatment of bronchiectesis
Route Antibiotics Dose and duration
Oral Amoxicillin/clavulanic
acid
625 mg BD for 10 days
Quinolone (ciprofloxacin) 750 mg BD for 7 to 10 days
Azithromycin 500 mg OD for 7 to 10 days
Doxycycline 100 mg BD for 10 days
Intravenous Cefuroxime 750 mg TDS for 10 days
Ceftriaxone 2 g BD for 7 to 10 days
moxicillin/clavulanic acid1.2 g TDS for 8 to 10 days
IfPseudomonas is
causative organism isolated
Piperacillin/tazobactum 4.5 gTDS for 10-14 days
Ceftazidime 2 g BD for 10 to 14 days


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Initially I/V followed by
oral ciprofloxacin 750 mg
for 10-14 days
Meropenem +
Aminog lycoside (dose as
per weight)
Gentamicin or amikacin
given once daily infusion
1 g TDS for 10 to 14 days
 Anti-inflammatory therapy
- Corticosteroids-Inhaled and oral
- NSAIDs -Inhaled and oral
Additional agents
- Long-actingβ agonists
- Long-acting anticholinergics
- Methylxanthines
- LT receptor antagonists
Non pharmacological treatment
 Surgical treatment plays only a small role in the present day management of
bronchiectasis
 Chest Physiotherapy
Physiotherapy techniques available for use in bronchiectasis
Independent techniques-Active cycle of breathingtechniques, Autogenicdrainage
Device-dependant techniques
- Positive expiratory pressure


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Independent techniques-Active cycle of breathingtechniques, Autogenicdrainage
Device-dependant techniques
- Positive expiratory pressure
- Oscillating positive expiratory pressure
- intrathoracic: Flutter, Acapella
- extrathoracic:high-frequency chest wall oscillations
- Intermittent positive pressure breathing
- Noninvasive ventilation
- Test of incremental respiratory endurance
Manual techniques
- chest percussion/clapping
- chest wall vibrations
- overpressure
- Gravity-assisted positioning
- Mo dified postural drainage
Complications
 Infective exacerbations occurring in patients with bronchiectasis are marked by both
increased volume and purulence of sputum. They may follow upper respiratory tract
infections in much the same way as exacerbations of chronic bronchitis.


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 Haemoptysis occurs commonly in bronchiectasis. Such episodes are usually small,
although major (>200mL per 24h) or rarely massive (>1000mL per 24h) haemoptyses
may occur.
 Chronic paranasal sinusitis occurs in a high percentage of patients with bronchiectasis and
is very common in severe cases.
 Brain abscess, operative complications include haemorrhage, atelectasis, pneumonia,
empyema, bronchopleuralﬁstula and pneumothorax.
ROLE OF PHYSIOTHERAPY IN PULMONARY REHABILITIATION
 Pulmonary rehabilitation is a multidisciplinary service directed to a person with
pulmonary disease by an interdisciplinary team of specialist, with the goal of achieving
and maintaining the individual’s maximum level of independence and functioning in the
communi ty.


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and maintaining the individual’s maximum level of independence and functioning in the
communi ty.
 The main aim of pulmonary rehabilitation is to promote healthy attitudes and recognition
of the benefits of exercise in the management of a variety of conditions.
 Other aims of pulmonary rehabilitation are
- Reduce dyspnoea,removal of secretion.
- Improving thoracic mobility and increasing lung,increasing endurance and strength
of muscles (peripheral and respiratory)
- Reduction of fatigue and energy conservation,ensure long term commitment to
exercise.
 Techniques to provide relaxation and promote breathing are
- Diaphragmatic breathing = ask the patient to recruit diaphragm by placing the hand on
abdomen.


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- Diaphragmatic breathing = ask the patient to recruit diaphragm by placing the hand on
abdomen.
 Segmental breathing = keeping the hands on the segment which is to be treated and
asking the Patient to fill the air under the hands.
- Pursed lip breathing = inhaling through nose and exhaling through pursed lips.
 Techniques to humidify the air mobilize the secretion and provide supplemental O2.
- Humidifier = It is used to humidify the inhaled air, it is very important when the upper
airway bypassed and Patients who has thick and tenacious secretions.
- Nebulizer= Administration of Nebulizer containing Saline water, Bronchodilators or
Mucolytics are used to liquify the secretions and to dilate the narrowed or spasmodic
airways.


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Mucolytics are used to liquify the secretions and to dilate the narrowed or spasmodic
airways.
- Oxygen therapy = It is administered when the patient‘s ventilator system is
insufficient to provide required amount of oxygen to the body either during rest or
during exercise.
 The techniques to remove the secretions are,


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- ACBT (Active Cycle of Breathing Technique): It consists of repeated cycles of 3
ventilatory     phases:breathing control, thoracic expansion and FET (Forced
Expiratory Techniques)
- AD (Autogenic Drainage): It uses diaphragmatic breathing to mobilize secretions by
varying expiratory airflow.
- Postural Drainage along with Percussion Vibration and Shaking: In PD Patient is
placed in positions that allow the bronchopulmonary trees to be drained with
assistance of gravity.
- Manual Hyperinflation: It is used in patients on endotracheal tube or tracheostomy
two caregivers are needed one to use the bag to hyperinflate the lung during
inspiration and provide a quick release to allow rapid exhalation. And second to apply
shaking or vibrations at beginning of expiration.


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inspiration and provide a quick release to allow rapid exhalation. And second to apply
shaking or vibrations at beginning of expiration.
- Positive Expiratory Pressure(PEP): It consists of a mouthpiece to which one way
valve is connected which is attached with expiratory resister which provides pressure
during expiration which helps in avoiding the collapsing airway and remove the
secretions.
- High Frequency Chest Compression (HFCC): It is used to give oscillations and
compressionsto whole lungs in sitting position helps in mucus clearance.
- In diseases like Pleural Effusion the fluid gets accumulated in the pleural cavity so for
that positioning in such a way that gravity assists the drainage of fluid faster through


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that positioning in such a way that gravity assists the drainage of fluid faster through
ICD occurs likeside lying with sound side up and deep inspiration followed with
maximum expiration eg. ballooning, bubble making etc.


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365
Chapter 18
PEDIATRIC CONDITIONS
NEWBORN CARE
Salient features
Treatment
Establishment of breathing at birth
 Most newborns cry immediately at birth and therefore needno assistance to establish
breathing. If the baby is preterm, meconium stained or some evidence of infection, not
crying or breathing or with poor muscle tone, then proceed to initial steps of resuscitation.
 For term babies, use 100% oxygen when baby is cyanotic or when positive pressure
ventilation is required. If room air is being used, supplementary oxygen should be
available to use if there is no appreciable improvement within 90 seconds of birth. If
supplemental oxygen is not available, positive pressure ventilation should be continued
with room air.


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supplemental oxygen is not available, positive pressure ventilation should be continued
with room air.
 Infants without signs of life (no heart beat and no respiratory effort) after 10 minutes of
resuscitation show either a high mortality or severe neurodevelopmental disability. After
10 minutes of continuous and adequate resuscitative efforts, discontinuation of
resuscitation may be justified if there are no signs of life.
Hypothermia
 Identification of hypothermia. An axillary (or rectal) temperature <36.0°C is
hypothermia. Such a baby would feel cold totouch on the abdomen and periphery.
 Identification of cold stress: Baby's peripheries are cold but abdomen is warm. This
usually corresponds to axillary temperature of 36-36.4°C.
 Prevention of hypothermia.


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usually corresponds to axillary temperature of 36-36.4°C.
 Prevention of hypothermia.
- Dry the baby with warm dry linen at birth. Discardwet linen and wrap in dry linen.
Place baby after birth under a radiant warmer or 200 Watt bulb (placed at a distance of 45 cm
above the baby). If neither is available, place the newborn infant on the mother's chest
 Essential newborn care (ENC) is a comprehensive strategy designed to improve the
health of newborns through interventions before conception, during pregnancy, at and
soon after birth, andin the postnatal period.
 ENC comprises of:
- Basic preventive newborn care such as care before and during pregnancy, clean
delivery practices, eye and cord care, prevention of hypothermia and infection


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delivery practices, eye and cord care, prevention of hypothermia and infection
- Early and exclusive breastfeeding on demand day andnight.
- Early detection of problems or danger signs (with priority for sepsis and birth
asphyxia) and appropriate referral and care seeking.


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and wrap baby and mother together to prevent heat loss from the exposed skin surfaces of
the baby.
- Ensure that there are no open windows or fans turning in the delivery
area where baby is being delivered or being observed.
- Suction mouth and then nose with mucous sucker
- Delay bathing of newborn for the first few days; this will prevent hypothermia. However,
baby may be wipedwith warm clean water to remove dried blood, vernix or secretions.
Care must be taken to ensure that the room is warm and draught free when the baby is
being cleaned or bathed. The baby should immediately be wrapped in dry linen after
being wiped dry.
 After birth and for the first few days thereafter keep mother and baby in close proximity


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being wiped dry.
 After birth and for the first few days thereafter keep mother and baby in close proximity
with baby being adequately clothed. In cold weather, the baby must have 2 layers of
cotton vest with a woolen sweater, cap, socks and legs should be covered and baby should
be wrapped in a blanket.  In summer, cotton dress with a cotton diaper wrapped in a
cotton cloth.
Prevention of infection
 Always clean hands with soap and water and wear sterile gloves if available before
conducting the birth of the baby and while examining babies during the first few days of
life.
 A sterilized blade (if that is not available a new razor blade or a blade boiled for at least
20 minutes) must be used for cutting the cord at delivery. The cord tie used must be


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20 minutes) must be used for cutting the cord at delivery. The cord tie used must be
sterile or boiled for 20 minutes before used for tying the cord after birth.
 The surface for conducting delivery and placing the baby after birth must be clean.
 Do not apply anything to the cord or eyes after birth.
 Do not give prelacteal feeds.Give exclusive breast-feeding from birth.
Exclusive breastfeeding
 Advise mothers to start breast feeding within one hour of birth. Not to give any prelacteal
feeds such as honey, water, etc.
 Give breast feeds to baby on demand. Give the baby exclusive breast feeding for at least
first 6 months of life. However, there may be situations where it may not be possible to
provide human milk i.e., maternal death, severe maternal illness, HIV positive mothers


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provide human milk i.e., maternal death, severe maternal illness, HIV positive mothers
and documented lactational inadequacy.
 Not to give water to the baby during period of exclusivebreast feeding.
Early identification of high-risk newborns
 Babies born to mothers with eclampsia, antepartum haemorrhage, diabetes etc. are
considered as high-risk newborns and delivery should be conducted at a centre where all
facilities for the care of the newborn are available. The following examination at birth or
during the first few days would help detect high risk babies who are in need of immediate
referral to an appropriate health facility which has adequate newborn care.


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 Weigh baby. Babies with birth weights <2000 g are at increased risk of morbidity and
mortality and need careful assessment by a physician trained in child health.
 Examine for major malformations.Most major and life threatening malformations such
as neural tube defects, oesophagealand anal atresias, diaphragmatic hernia, etc. can be
detected at birth by careful examination. Some important clues to an underlying
malformation are non-passage of meconium at 24 h of age or non-passage of urine at 48 h
after birth.
 Sucking, activity andcry.Newborn infants who have poor sucking, are less active than
normal and have a weak cry are very ill and need immediate referral.
 Respiratory distress.Babies who have a respiratory rate of >60 bpm (counted for at least


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 Respiratory distress.Babies who have a respiratory rate of >60 bpm (counted for at least
1 minute and persisting on repeat count) or have severe subcostal retractions have
respiratory distress and need immediate referral.
 Identification of severe jaundice.Yellow staining of the skin within 24 h of age or when
yellow staining of the skin includes the palms and soles at anyage, this is severe jaundice
and needs immediate referral.
Immunization
All newborns delivered at a health facility shouldbe given BCG and one dose of oral
polio vaccine within 24 hours of birth.
LOW BIRTH WEIGHT BABIES
Salient features
Treatment
Indications for hospitalization are:
 Birth weight of less than 1800 g, gestation age of less than 34 weeks, neonate who is not


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Treatment
Indications for hospitalization are:
 Birth weight of less than 1800 g, gestation age of less than 34 weeks, neonate who is not
able to take feeds from the breast or by cup (katori) and spoon (irrespectiveof birth
weight and gestation),sick neonate (irrespective of birth weight and gestation).
Keep the LBW babies warm
Room temperature should be kept between 28-30°C. Following methods may be used:
 Maternal-baby skin to skin contact (Kangaroo mother care). Place the naked baby
between the mother's breasts. Wrap baby and mother with a shawl. Cover the baby's head
with a cap.
 Proper clothing- cap, woollen sweaters, socks and mittens.Blankets,Overhead radiant
warmer, Incubator
 Nutrition-guidelines to provide fluids and nutrients to low birth weight babies are given in


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warmer, Incubator
 Nutrition-guidelines to provide fluids and nutrients to low birth weight babies are given in
following table.
 Low birth weight (LBW) baby is one who weighs less than 2500 g at birth. Low birth
weight may result from either prematurity (gestational age <37 weeks) or intrauterine
growth retardation (IUGR), which is also called small-for-date baby.


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Table 1. Guidelines to provide fluids and nutrients to low birth weight babies (LWB)
Age Category of neonates
Birth weight <1200 g 1200-1800 g >1800 g
gestation <30 weeks 30-34 weeks >34 weeks
Initial Intravenous fluids
(60 ml/kg/day)with feed
Gavage
(60 ml/kg/day)
Breast feeding.Ifnot
satisfactory,spoon feeds
After 1-3 days Gavage (15-30 ml/kg/d),
increase by 15-30 ml/kg/day
to a maximum of 180
ml/kg/day of expressed
breast milk
Katori/spoon
maximum of
150-180 ml/kg/d
Breast feeding
Later
(2-4 weeks)
Katori/spoon (150-180
ml/kg/day)
Breast feeding Breast feeding
Vitamin supplementation
 Vitamin K 1.0 mg IM at birth
 Vitamin A 1000 IU orally daily-from 1 week age onwards
 Vitamin D 400 IU orally daily-from 2 weekage onwards


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 Vitamin K 1.0 mg IM at birth
 Vitamin A 1000 IU orally daily-from 1 week age onwards
 Vitamin D 400 IU orally daily-from 2 weekage onwards
 Iron 2-4 mg/kg/day orally daily-from 4 weeks age onwards
 Vitamin E, calcium and phosphorus supplementation in very LBW (<1500 g, <32 week
gestation).
Early detection of sickness by periodic evaluation
Referral to higher centre in the presence of any one or more ofthe following signs: Lethargy,
refusal to feed, hypothermia, respiratory distress, grunt, apnoea, abnormal weight gain,
jaundice over soles and palms, abdominal distension, feed intolerance, cyanosis, pallor,
seizures and bleeding.
NEONATAL JAUNDICE
Salient features
 C haracterized by yelloweyes, mucus membrane or skin.C ommon during the first


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seizures and bleeding.
NEONATAL JAUNDICE
Salient features
 C haracterized by yelloweyes, mucus membrane or skin.C ommon during the first
week of life. About 60% of newborn develop transient, self-limiting jaundice-
Physiological jaundice. About 5% of newborn develop pathological jaundice.
 Progression of jaundiceis cephalopedal. Yellow colouration of trunk indicates the
serum bilirubin to range between 10 and 12 mg/dl whereas staining of palms and
soles is ominous as it indicates a serum bilirubin of more than 15 mg/dl.
 Physiological jaundice is characterized by its characteristic timeline– appears within
3rd day and resolves within 14 days of birth.Pathological jaundice may cause
kernicterus when unconjugated bilirubin exceeds 20 mg/dl. Ifpersists> 2 weeks, the


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kernicterus when unconjugated bilirubin exceeds 20 mg/dl. Ifpersists> 2 weeks, the
baby should be investigated for cholestatic jaundice.


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Treatment
All neonates need assessment for jaundice. But not all jaundiced neonates require treatment.
 Phototherapy:
- Mainstay of treatment and usually initiated when total serum bilirubin level reached
phototherapy threshold (10 to 12 mg/dl for preterm and 15 mg/dl for term babies).
- The naked infant (with covered eyes) is kept about 45 cm below the phototherapy unit.
Phototherapy is administered continuously and interrupted only for nursing and feeding
purpose with change in position every 2-4 hours.
- Failure of phototherapy is defined as inability to observe a decline in bilirubin of 1-2
mg/dl after 4-6 hour and/or to keep the bilirubin level below the exchange transfusion
level.
 Exchange transfusion:


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mg/dl after 4-6 hour and/or to keep the bilirubin level below the exchange transfusion
level.
 Exchange transfusion:
- It is indicated when bilirubin level exceeds threshold levels for age and gestational age or
have features of bilirubin encephalopathy.
- Choice of blood:  Group and type specific, compatible packed RBCs with anticoagulant,
<7 days old.
- Complications include hypothermia, fluid overload, infection, electrolyte imbalance,
hypoglycaemia, thrombosis and death.
- Monitoring of heart rate, saturation, respiration, temperature, glucose and bilirubin levels
is required.
 Adjunct treatment:
- Intravenous immunoglobulin
- Phenobarbitone
Follow up
 Neurodevelopmental assessment at 3, 6, 9 and 12 months of age.
 Hearing assessment (BERA) at 3 month of age.


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- Phenobarbitone
Follow up
 Neurodevelopmental assessment at 3, 6, 9 and 12 months of age.
 Hearing assessment (BERA) at 3 month of age.
 Prognosis is excellent in uncomplicated cases.
 Prognosis is guarded if jaundice is severe and requiring exchange transfusion.
MANAGEM ENT OF COMMON CLINICAL PROBLEMS IN NEWBORNS
 Regurgitation of feeds and vomiting:N on-projectile expulsion of stomach contents
without force (regurgitation) is normal andneeds advice regarding feeding technique.
 Bowel disorders: No medication should be prescribed for passage of stools after each feed
(exaggerated gastrocolic reflex) as this is normal in some babies. From 3rd to 14th day
many exclusively breast-fed babies pass loose stools (10-15 times/ day) without


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many exclusively breast-fed babies pass loose stools (10-15 times/ day) without
illness/dehydration. These are transitional stools and require no medication.
 Delayed passage of urine: Non-passage of urine by 48 hours after birth may suggest
urinary tract anomalies. Such babies need to be investigated. Crying before passing urine
is normal.


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 Dehydration fever: Transitory moderate fever (up to 38.5°C) usually during the second or
third day of life in summer months in an active baby, who sucks well, is normal and
responds to lowering the environmental temperature.
 Excessive crying: Most baby cry when either they are hungry or arehaving discomfort
such as due to full bladder before passing urine, wet napkin, nose block etc. Excessive
inconsolable crying or high-pitched crying is indicative of meningitis or any other painful
inflammatory conditions.
 Umbilical sepsis: If there is pus discharge not extending to periumbilical skin, apply 10%
gentian violet or povidone iodine locally twice a day. However, if there is periumbilical


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gentian violet or povidone iodine locally twice a day. However, if there is periumbilical
erythema or induration, administer syrup erythromycin 40 mg/kg/day in 3-4 divided
doses. If the newborn hasany other high risk factor, refer to a higher centre.
 Umbilical granuloma: A red flesh-like nodule at the base of umbilical cord can be
managed by cautery with silver nitrate or application of common salt for 3 to 4 days.
 Engorgement of breasts in both sexes and vaginal bleeding after 4 days of birth is normal.
IMMUNIZATION SCHEDULE
 A number of vaccines available for childhood immunization to protect against are
important national causes of childhood morbidity and mortality.
 Both killed and live vaccinescan be administered simultaneously without decreasing the


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 Both killed and live vaccinescan be administered simultaneously without decreasing the
efficacy of the individual vaccine. However, vaccines be administered at different sites
using separate needles for each component. A gap of 1 month is recommended between 2
live vaccines if not given together.
 Avoid giving injections if skin is infected or compromised by a skin lesion. Prepare skin
with a disinfectant. Always use a sterile syringe and needle for each injection and to
reconstitute each unit of medication. After use syringes and needles should be disposed
off carefully as per guidelines together.
Table 2. National immunization schedule (Universal Immunization Programme)
Vaccine Age recommended
BCG Birth or 6 weeks.
OPV Birth, 6, 10, 14 weeks, 15-18 months.


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Vaccine Age recommended
BCG Birth or 6 weeks.
OPV Birth, 6, 10, 14 weeks, 15-18 months.
Hepatitis B Birth, 6, 10, 14 weeks
DPT 6, 10, 14 weeks, 15-18 months.
Measles 9 months.
MMR 15-18 months.
DT 5 years.
TT 10 and 16 years (if given for first time at this age,
give 2 doses at 4 weeks Interval).


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Table 3. Immunization recommended by the Indian Academy of Pediatrics
Vaccine Age recommended
BOG From birth to 2 weeks
OPV At birth; 6,10 and 14 weeks
DTP 6,10 and 14 weeks; 15-18 months; 5 years (DT)
Hepatitis B Birth, 6 and 14 weeks or Birth, 1 and 6 months or 6,
10 and 14 weeks
Hib 6,10 and 14 weeks; 15-18 months
Measles 9 months + (special circumstances (epidemics) may
be given earlier
than 9 months)
MMR 15-18 months
Typhoid 2 years + (revaccination 3-4 years)
TT 10 and 16 years
2 doses of TT Pregnant women at I month interval
Newer Vaccines
Varicella Above 1 year
Hepatitis A Above 1 year
 If the mother is known to be HBsAg negative, HB vaccine can be given along with DTP at 6, 10


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Varicella Above 1 year
Hepatitis A Above 1 year
 If the mother is known to be HBsAg negative, HB vaccine can be given along with DTP at 6, 10
and 14 weeks. If the mother's status HBsAg status is not known, it is advisable to start vaccination
soon after birth to prevent perinatal transmission of the disease. If the mother is HBsAg positive
(and especially HBsAg positive), the baby should be given Hepatitis B immune globulin (HBIG)
within 24 hours of birth, along with HB vaccine.
 The only advantage of combinationvaccines is convenience, however, should not be viewed as
more effective than vaccines given separately. The manufacturer's instructions should be strictly
followed whenever "mixing" vaccines in the same syringe prior to injections.
Immunization in special circumstances


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followed whenever "mixing" vaccines in the same syringe prior to injections.
Immunization in special circumstances
 Immunization in preterm infants: In general, all vaccines may be administered as per
schedule according to the chronological age irrespective of birth weight or period of
gestation. Very low birth weight/ preterm babies can be given immunization if they are
stable otherwise.
 Children receiving corticosteroids: Children receiving oral corticosteroids in high doses
(prednisolone 1-2 mg/kg/day) for more than 14 days should not receive live virus
vaccines until the steroid has been discontinuedfor at least one month. Killed vaccines
are safe but may not be completely effective in such situations. Patients on topical or


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are safe but may not be completely effective in such situations. Patients on topical or
inhaled steroids should not be denied their age appropriate vaccine.
 Children awaiting splenectomy: Immunization with pneumococc al, Hib and
meningococcal vaccine should be initiated a few weeks prior to splenectomy.
 Vaccination in children with HIV infection: Immune response may be suboptimal as it
depends on the degree of immunodeficiency at that point of time. Readministration of


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Pediatric Conditions
372
childhood immunization may be considered when their immune status has improved
following anti-retroviral therapy.
 Lapsed immunization: There is no need to restart a vaccine series regardless of the time
that has elapsed between individuals dose. In case of unknown or uncertain immunization
status, however, it is appropriate to start the schedule as for an unimmunized child.
 Minor illnesseslike fever, diarrhoea, respiratory infections and malnutrition should not be
construed as contraindications to immunization.
FLUID AND ELECTROLYTES THERAPY IN CHILDREN
Fluid and electrolyte therapy is divided into three phases: Correction of pre-existing deficits
like rehydration therapy for diarrhea. Provision of maintenance requirements for normal


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like rehydration therapy for diarrhea. Provision of maintenance requirements for normal
metabolism, correction of ongoing losses (diarrhea, vomiting) or removal (suction,
aspiration). The maintenance requirements are as follows:
A guideline for estimating daily fluid and electrolyte requirement in a normal child under
normal conditions is:
Weight Fluid requirement
3-10 kg 100 ml/kg/day
10-20 kg 1000 ml + 50 ml/kg/day for each kg above 10.
> 20 kg 1500 ml + 20 ml/kg/day for each kg above 20.
Maintenance fluid requirement replaces water loss through skin (2/3 of losses), GIT,
respiration, and urine. These losses are affected by ambient humidity, clothing, body
temperature, respiratory rate, and age of the child. Situation specific adjustments are


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temperature, respiratory rate, and age of the child. Situation specific adjustments are
necessary when calculating maintenance fluids. The most commonly employed intravenous
maintenance fluid employed in children is N/5 (0.18%) sodium chloride in 5% glucose +
potassium chloride 20 mEq/ Liter. Commercially it is available as Isolyte P, Kidral etc.
Maintenance requirements in newborns
The following table provides the normal fluid electrolyte requirements in newborn babies.
Table 4. Normal fluid requirements of newborns
Age (days)Total fluids Glucose/Dextrose (ml/kg/day) Electrolyte
1 60 10% Dextrose in water None
2 70-80 -do- None
3 80-90 -do- Sodium 2-3 mmol/kg/day
Potassium 2 mmol/kg/day
4 90-100 -do- -do-
5 100-110 -do- -do-
6 110-120 -do- -do-


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 From day 3 onwards, fluid containing glucose-electrolyte mixture can be provided using
commercially available paediatric maintenance intravenous solutions provided 5% weight
loss has been documented.
 The fluid and electrolyte requirement from day 7-28 remains the same. However, in
babies <1500 g the fluid requirement after day 7 need to be increased by 10-20 ml/kg/day
till a maximum of 150 ml/kg/day.
Conditions that increase fluid requirement
 Fever: for every 1°C increases over 37.5°C, the fluid requirement increases by 10
ml/kg/day.
 Phototherapy: this increases fluid requirement by 10-20 ml/kg/day.
Conditions that decrease fluid requirement
 Congestive cardiac failure: Fluid requirements are reduced to 2/3rd of the normal need for
that age.


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Conditions that decrease fluid requirement
 Congestive cardiac failure: Fluid requirements are reduced to 2/3rd of the normal need for
that age.
 Renal failure: In cases of decreased urinary output, the fluid regimen is 400 ml/m2/day for
insensible water losses plus urinary output over the day. Potassium should be added with
caution or omitted in suspected cases of acute renal failure.
IRON DEFICIENCY ANAEMIA
Salient features
Non -pharmacological treatment
 After period of exclusive breastfeeding (6 months), cereal based diet should be added.
Encourage green leafy vegetables and fruits.
 Treatment depends on hemoglobin levels and age of the patients
Pharmacological treatment-Oral Iron Therapy


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 Treatment depends on hemoglobin levels and age of the patients
Pharmacological treatment-Oral Iron Therapy
 Oral ferrous salts (sulphate, gluconate etc) are the preferred therapeutic iron preparations.
 Therapeutic iron dose: 4 mg/kg/day of elemental iron in 2– 3 divided doses to be given
between meals for 2 months after normal Hb concentration for age is achieved.
 In prematurity start iron syrup from 2nd week of life to 1 year.
 Response to therapy– decreased irritability and improved appetite is seen within 12– 24
hours. Rise in Hb levels seen within 7 days at the rate of 0.25– 0.4 g/dl/day.
 Iron deficiency anaemia occurs mainly due to dietary lack of iron containing food.
 RBC indices like reticulocytecount, serum iron concentration,total iron binding


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 RBC indices like reticulocytecount, serum iron concentration,total iron binding
capacity(TIBC) etc aids in diagnosis of iron deficiency anaemia.
 C linical features are easy tiredness, lack of concentration, decreased school
performance, growth retardation. Severe cases may present withCCF.
 Iron deficiency is uncommon in term breastfed childrenbut prematurity, perinatal
blood loss or cow milk feeding may lead to deficiency in infancy.


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 If the response is inadequate, check for the prescribed dose, compliance, presence of
diarrhoea or malnutrition, infections orβ thalas semia trait mistakenly diagnosed as iron
deficiency anaemia.
Parenteral Iron Therapy
 It is rarely required. However, when oral iron is not tolerated, severe ADRs to oral iron or
presence of malabsorption syndromes, parenteral iron therapy may be used.
 Total dose of iron is: Iron(mg) = wt(kg) x Hbdeficit (g/dl) x 4
 Injection iron dextran or iron sorbitol citrate (50 mg/ml) deep gluteal IM injection is
preferred.
Blood Transfusion
 When Hb is less than 3g% or Hb 4-6 g% in cardiac compromised patient
 PCV 15 ml/kg at rate of 4-5 ml/kg/hour
Patient/parent education


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 When Hb is less than 3g% or Hb 4-6 g% in cardiac compromised patient
 PCV 15 ml/kg at rate of 4-5 ml/kg/hour
Patient/parent education
 Iron deficiency anaemia occurs generally due to dietary deficiency of iron. Once the diet is
modified, the patient should stick to that diet.
 Iron should be taken between meals and never with tea or milk
 Intake of iron usually causes harmless black discolouration of teeth and stools. The teeth
discolouration can be prevented by rinsing the mouth with water after doses.
MEGALOBLASTIC ANEMIA
Salient features
Pharmacological treatment
 Folic acid Deficiency- Oral folic acid- <6 months of age: 15 mcg/kg for 3 months
7 months– 13 year:  1 mg for 3 weeks followed by 0.1-0.5 mg for next 3 months
 Vitamin B12 Deficiency
- Oral/sublingual vitamin B12


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7 months– 13 year:  1 mg for 3 weeks followed by 0.1-0.5 mg for next 3 months
 Vitamin B12 Deficiency
- Oral/sublingual vitamin B12
500-1000 mcg/day for 4-6 weeks
25-50 mcg/day for next 3 months
- Parenteralvitamin B12
100 mcg IM for 2 weeks
100-250 mcg/day IM till complete correction
 Folic acid and vitamin B12 are two most essential micronutrients.Deficiency of both
occurs due to dietary lack. B12 deficiency is especially seen in strict vegetarians as its
main dietary source is non vegetarian food.
 Detailed diet history, Hbconcentration, reticulocyte count, RBC indices help
establishing diagnosis of megaloblastic anemia.
 C linical features are same as iron deficiency anemia. Young child may show tremors
and typical pigmentation over knuckles.


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Pediatric Conditions
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PROTEIN ENERGY MALNUTRITION
Nutritional marasmus and kwashiorkor are two extreme forms of malnutrition. Such extreme
forms are rare; most cases suffer from mild and moderate nutritional deficit.
Salient features
Assessment of nutritional status
Undernutrition is classified by WHO into moderate and severe forms as shown in the
following table. Reference values for weight for height are also provided.
Table 5. WHO classification for severity of undernutrition
Moderate undernutrition Severe undernutrition
Symmetrical edema No Yesa
Weight for height
(measure of wasting)
SD scoreb -2 to-3
(70– 79% of expectedc)
SD score <-3
(<70% of expected)
Height forage
(measure of stunting)
SD scoreb -2 to-3
(85– 89% of expectedc)
SD score <-3
(<85% of expected)


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SD score <-3
(<70% of expected)
Height forage
(measure of stunting)
SD scoreb -2 to-3
(85– 89% of expectedc)
SD score <-3
(<85% of expected)
a. This includes kwashiorkor and marasmic kwashiorkor
b. SD score = Observed value– expected value
Standard deviation of reference population
c. Median (50th percentile of NCHS standards).
Table 6. NCHS/WHO Normalized reference values for weight-for-height/length
Boys' weight (kg) Length(cm) Girls' weight (kg)
-3 SD -2 SD Median Median -2 SD -3 SD
2.2 2.5 3.3 50 3.4 2.6 2.3
2.7 3.3 4.3 55 4.3 3.3 2.8
3.7 4.4 5.7 60 5.5 4.3 3.7
5.0 5.7 7.1 65 7.0 5.5 4.8
6.3 7.0 8.5 70 8.4 6.8 6.0
7.4 8.2 9.8 75 9.6 7.9 7.0
8.3 9.2 10.9 80 10.6 8.8 8.0
 Milder forms may just present with failure to thrive i.e. decreased rate of weight gain.


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7.4 8.2 9.8 75 9.6 7.9 7.0
8.3 9.2 10.9 80 10.6 8.8 8.0
 Milder forms may just present with failure to thrive i.e. decreased rate of weight gain.
 Marasmus is characterized by gross wasting of muscle and subcutaneous tissues
resulting in emaciation, marked stunting, and no oedema.
 Markedly retarded growth, psychomotor changes, and oedema of dependent parts are
three essential clinical features of kwashiorkor.
- PEM is usually associated with anaemia due to iron, protein, vitamin B12 or folic acid
deficiency, xerophthalmia due to vitamin A deficiency, andother micronutrient
deficiencies magnesium, copper, zinc,vitamins B, C, D and K.


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8.9 9.9 12.1 85 11.8 9.7 8.6
9.8 10.9 13.3 90 12.9 10.7 9.5
10.7 11.9 14.5 95 14.1 11.6 10.4
11.6 13.0 15.7 100 15.4 12.7 11.3
12.7 14.2 17.1 105 16.7 13.8 12.3
13.8 15.4 18.7 110 18.2 15.0 13.4
SD -standard deviation score (or z score).
Indian Academy of Paediatrics (IAP) takes a weight of more than 80% of expected for age as
normal.  Grades of malnutrition are:Grade I (71-80%), Grade II (61-70%), Grade III (51-
60%) and Grade IV (< 50%) weight of expected value for that age.
Treatment
Mild to moderate undernutrition
 Domiciliary treatment of malnourished children is economical, offers in-built advantage of
practical health education, and is associated with minimal recurrence risk.


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practical health education, and is associated with minimal recurrence risk.
 The parents are advised to increase the food intake of the child, adequate amount of calories
and protein in the diet, prepared from the locally available, inexpensive foods.
 Keep the child under surveillance by using a growth chart and effort should be made that he
does not slip down to severe malnutrition.
Severe malnutrition
 Initial treatment involves managing complications. The aim is to treat complications and
stabilize the child.
 Severely wasted children and those with oedema need hospitalization. Other indications for
admission in an undernourished child are severe dehydration, severe diarrhoea, hypothermia,
shock, systemic infection, jaundice, bleeding, age less than one year, or persistent loss of


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shock, systemic infection, jaundice, bleeding, age less than one year, or persistent loss of
appetite.
 Those with severe stunting alone may be managed in the community.
 Refer, when child fails to (i) regain appetite by day 4, (ii) loose oedema by day 5, or (iii) gain
weight by day 10 of therapy.
 Children who fail to respond to treatment should be screened for faulty feeding, inadequate
feeding, persistent diarrhoea, malabsorption, giardiasis, shigellosis, amoebiasis, otitis media,
pneumonia, UTI, fungal infections, scabies, tuberculosis, helminthiasis, malaria, and
HIV/AIDS. If the search proves futile, one should also look for any underlying
immunological disease, inborn errors of metabolism and malignancies.Hospital management


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immunological disease, inborn errors of metabolism and malignancies.Hospital management
of severe malnutrition is given in the following table.
Table 7.Hospital management of severe malnutrition
Problem Management
Hypothermia (rectal
temperature <35.5ºC)
 Keep under heat source such as radiant warmer, room heater, hot air
blower or 200 watt bulb and warm upto rectal temperature 37ºC


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within 2– 3 hours
 Ifelectric gadgets are not available, cover the child well. Warm up
with kangaroo technique (placing the naked child against mothers
bare chest and covering them both together with cloth and blanket)
 Monitor rectal temperature half hourly. Investigate and treat for
infection and hypoglycemia.
Hypoglycemia (blood
sugar <54 mg/dl)
 10% glucose 5– 10 ml/kg IV immediately followed by IV infusion
of a dextrose containing solution.
 Stop IV fluids as soon as blood glucose stabilizes and switch to oral
feeds.
Dehyd ration (as
assessed by WHO
classification)
 Some dehydration is to be corrected with 2/3rd diluted ORS over 12
hours.
 Severe dehydration: Administer Ringer’s Lactate or N/2 5% saline


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 Some dehydration is to be corrected with 2/3rd diluted ORS over 12
hours.
 Severe dehydration: Administer Ringer’s Lactate or N/2 5% saline
30 ml/kg 2 hours. If still pulse is not palpable, consider septic shock
and manage accordingly.
Severe dehydration
(weak pulse, oliguria)
 If pulse improves after 2 hours, give N/6 5% saline at 10 ml/kg/hour
in next 10 hours followed by 5 ml/kg/hr in next 12 hours.
 After dehydration is corrected, start on maintenance fluids at 75-100
mg/kg/day till feeding is established.
 Add potassium to IV fluids at 30 mEq/l after the child passes urine.
Septic shock (clinical
features similar to
severe dehydration)
 Give blood or plasma transfusion at 10 ml/kg over 3 hours.
 Start antibiotics as given in Infections


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features similar to
severe dehydration)
 Give blood or plasma transfusion at 10 ml/kg over 3 hours.
 Start antibiotics as given in Infections
 Fluid management is similar to that of severe dehydration
Dyselectrolytemia There is a risk of hypernatremia and hypokalemia.
 Restrict sodium intake and do not give hypertonic saline even in face
of hyponatremia.
 Potassium supplements should be given at 30– 40 mEq/L per day of
fluids provided the child is passing urine freely.
Infections  No apparent signs of infection and no complications, then give
cotrimoxazole (5 mg/kg of trimethoprim) twice daily for 5 days.
 Presence of septic shock, hypoglycemia, hypothermia, skin,
respiratory, urinary infections or sick looking, give injection


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 Presence of septic shock, hypoglycemia, hypothermia, skin,
respiratory, urinary infections or sick looking, give injection
ampicillin 50– 100 mg/kg IM or IV 6 hrly + gentamicin 7.5 mg/kg
IM or IV once a day for 7 days
 If no response to above antibiotics in 48 hours, add chloramphenicol
25 mg/kg IM or IV 8 hourly. Give every 6 hourly if meningitis is
suspected.
 If specific infections are detected such as dysentery, malaria,
pneumonia, worm infestation, tuberculosis, treat as per STG of that


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particular condition.
Congestive cardiac
failure (tachycardia,
cardiomegaly)
 Restrict fluid intake.
 Give injection furosemide 1 mg/kg stat.
Severe anaemia
(hemoglobin <4 gm
%)
 If JVP is elevated, give a single dose of Inj. digoxin 5 mcg/kg
 Give packed red cells 10 ml/kg in 4– 6 hours, carefully monitoring
cardiac status.
Vitamin A deficiency Give a single dose of vitamin A orally to all children less than 6
months – 50,000 IU, 6 months to 1 year– 1,00,000 IU, more than 1
year– 2,00,000 IU if the dose has not been given in the last month.
 If signs of vitamin A deficiency are present, repeat the above dose
twice– the next day and then after 2 weeks.
Vitamin K deficiency
or severe bleeding
 Injection vitamin K 2.5 mg IM single dose.
Magnesium
deficiency


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twice– the next day and then after 2 weeks.
Vitamin K deficiency
or severe bleeding
 Injection vitamin K 2.5 mg IM single dose.
Magnesium
deficiency
 Give 02 ml/kg of 50% solution ofmagnesium sulphate IV single
dose.
Folic acid deficiency Give folic acid 5 mg on day 1 followed by 1 mg/day.
Initiation of cure
First seven days aim: start nutrition
Starting point
Once complications are taken care of and child is ready to tolerate feeds.
Table 8. Initiation of cure
Start feeding  Initiate feed as early as possible.
 If oral feeding is not possible, give nasogastric feeding.
 Start with a lower volume of feed at frequent intervals, number
of feeds varying from 12 feeds on first and second day to 6 to 8
feeds on days 3– 7.


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of feeds varying from 12 feeds on first and second day to 6 to 8
feeds on days 3– 7.
 If tolerated, milk based diets are most suitable (80 kcal/kg/day)
and protein (0.7 gm/kg/day). The caloric intake should not
exceed 100 kcal/kg/day on the first day. Increased gradually over
one week to 150 kcal/kg/day of energy and 2– 3 gm/kg/day of
proteins. Total amount of fluids should be kept within 100– 125
ml/kg/day.
 Sugar and oil can be added to provide extra calories.
Lactose intolerance
(stool pH, 5.5 on two
separate
occasions)
 Reduce the total lactose load inthe diet by diluting the milk for 3
to 4 days or substituting a part of milk feeds by formulae based
on lactose free milk protein (calcium caesinate), sugar and oil,
soyabean, meat or vegetable protein mixtures.


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on lactose free milk protein (calcium caesinate), sugar and oil,
soyabean, meat or vegetable protein mixtures.
Other nutrients  Supplement the diet with minerals and trace elements as follows:


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379
potassium chloride (1.2 to 2.4 g/L of feed), magnesium chloride
(300 – 600 mg/L of feed), zinc acetate (20 mg per day), copper
acetate (2 mg/L of feed), selenium (6– 10 mcg/kg/day) and folic
acid (1 mg/day). Do not give iron at this stage. Add iron only
after one week of therapy.
 Vitamins of B complex are not useful in initial therapy.
Signs of
improvement
 During these seven days, a child of kwashiorkar will lose weight
and a marasmic child gains little or nothing because the tissue
gains are masked by excess water loss.
Rehabilitative phase
(2– 6 weeks)
 Aim: Restore normal weight for height.
 Starting point: Child has started showing signs of recovery of
appetite and changes in expression.
Intensive feeding
(too recover lost
weight)


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 Starting point: Child has started showing signs of recovery of
appetite and changes in expression.
Intensive feeding
(too recover lost
weight)
 Replace the initial milk diet with home diet as soon as possible.
 Provide therapeutic diet as follows: fluids 150 ml/kg/day, energy
175 – 200 kcal/kg/day, proteins 2– 4gm/kg/day.
 The diet prescribed for the child should be such which thefamily
can afford for the baby within its limited income, can be cooked
easily at home, does not perish easily, is culturally acceptable,
and easily available in the local market.
Treat concurrent
nutritional
deficiencies
 Start oral iron 3 mg/kg/day elemental iron once a day. Start other
vitamins including B, C, D, E at double the RDA.
 Continue potassium, magnesium, zinc, copper, selenium and


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vitamins including B, C, D, E at double the RDA.
 Continue potassium, magnesium, zinc, copper, selenium and
folic acid supplementation.
 Provide vitamin D 400 IU once daily for 4 weeks/.
NUTRITIONAL RICKETS
Salient features
Non -pharmacological treatment
 Encourage the child to play outdoors/ increase exposure to sunlight.
 Enhance dietary sources of vitamin D-dairy products, egg and fish liver oil.
Pharmacological treatment
 It isdefective mineralization of growing skeleton caused by deficiency of vitamin D
characterized by skeletal deformities like genu valgum/genu varum, broadening of
wrists, susceptibility to fractures, weakness, hypotonia and disturbances in growth.
Most often it is nutritional (lack of exposure to sunlight and inadequate dietary intake)


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Most often it is nutritional (lack of exposure to sunlight and inadequate dietary intake)
and occurs between 2 months to 2 years of age.
 X ray shows thatincreased thickness of epiphyseal growth plate,cupped with hazy
metaphyseal borders. S.calcium is generally normal/low, phosphate is low/normal and
alkaline phosphatase is raised in nutritional rickets.


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Pediatric Conditions
380
 Vitamin D 600,000 IU stat oral or IM (if patient is sick due to intercurrent infection).
 Repeat X-ray wrist after 4 weeks. If the response is positive, i.e. healing line of rickets is
seen on X-ray, continue oral vitamin D 400 IU/ day.
 If no response to therapy after 4 weeks refer to a highercentre for evaluation of non-
nutritional rickets.
Patient education
 Exposure to sunlight is beneficial for a child with rickets.
 No special type of oil is required for massage.
 Consumption of dairy products which are rich in vitamin D should be emphasized.
 Most of the deformities improve in the due course of time.
PICA
Salient features
Treatment
Pica below two years does not need any intervention.


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 Most of the deformities improve in the due course of time.
PICA
Salient features
Treatment
Pica below two years does not need any intervention.
Children with pica are at increased risk of lead poisoning, iron deficiency, bezoars, and
parasitic infections. They should be investigated for these problems and if present, treated
suitably.
PRIMARY NOCTURNAL ENURESIS
Most common cause in primary enuresis is inappropriate toilet training. Other causes could
be genetic, sleep disorder, reduced ADH at night. Psychological causes may be found in
secondary. Around 3% children have organic pathology, such as obstructive uropathy or UTI.
Salient features
Non -pharmacological treatment (effective in 30% cases)
 Rule out organic causes. Restrict fluid intakein the evening. Bladder exercises:


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Non -pharmacological treatment (effective in 30% cases)
 Rule out organic causes. Restrict fluid intakein the evening. Bladder exercises:
- hold urine as long as possible during the day.
- practice repeated starting and stopping the stream at the toilet bowl.
 Practice getting up from bed and going to the bathroom at bedtime before sleep.
 R epeated and chronic ingestion of non-nutrient substances including mud, plaster, paint,
earth, clay, etc.It is self-limiting and represents manifestations of family disorganization,
poor supervision, and emotional neglect.
 Involuntary discharge of urine after the age at which bladder control should have been
established (5 years).In primary nocturnal enuresis, child has never been dry at night


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established (5 years).In primary nocturnal enuresis, child has never been dry at night
while in secondary, child has been continent for at least 6 months before the child begins
to wet again.


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Pediatric Conditions
381
Pharmacological treatment
 Indicated only in children > 6 years where sufficient trial of non-pharmacological
management has failed.
 Tab. imipramine: 6-8 year (25 mg), 9-12 year (50 mg), >12 year (75 mg) once a day at
bedtime. Ordesmopressin acetate (nasal spray, 10mcg per spray): Start with 10 mcg
given at bedtime daily and increase gradually by 10 mcg/per week to a maximum of 40
m cg per day. If effective, it should be used or 3-6 months.
 Refer the patient to a higher centre if organic cause is suspected or when diagnosis is in
doubt.
Patient education
 Reassure the parents that condition is self-limiting.
 Ask the parents to maintain a diary record of dry nights; reward the child for such nights.
WHEEZY CHILD


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 Ask the parents to maintain a diary record of dry nights; reward the child for such nights.
WHEEZY CHILD
 Wheezing is a clinical symptom present in asthma and other illnesses including
bronchiolitis and other viral infection, foreign body inhalation, tuberculosis, pneumonia,
cystic fibrosis, hypersensitivity pneumonia and conditions compressing airways.
Wheezing during infancy could be due to viral infections.
 Wheezing inasthma is recurrent, gets worse in night and after exercise, seasonal and may
be associated with other allergic illnesses like atopic dermatitis, allergic rhinitis etc.
 Clinical features suggestive of other cause of wheezing are: neonatal onset, associated
with difficulty in feeding, choking or vomiting, localized findings in chest or abnormality


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with difficulty in feeding, choking or vomiting, localized findings in chest or abnormality
in cardiovascular system.
ACUTE BRONCHIOLITIS
Salient features
 It is an acute respiratory tract infection caused by respiratory syncytial virus.
Bronchiolitis commonly occurs in infants below 6 months of ageduringduring winter
and early spring.Symptoms -running nose for 2-4 days followed by cough, wheeze and
rapid respiration. With increasing severity of illness there may be lower chest indrawing,
difficulty in feeding, excessive crying due to hypoxaemia, cyanosis and respiratory
failure.H istory of viralURTI in other family members in the recent past.
 Normal or minimal increase in total leucocyte counts with relative lymphocytosis. X-ray


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 Normal or minimal increase in total leucocyte counts with relative lymphocytosis. X-ray
chest may show hyperinflation and small atelectasis. Clinical judgement remains the
gold standard criteria for hospital admission. SpO2 monitoring is the most consistent
clinical predictor of worsening.


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Pediatric Conditions
382
Non -pharmacological treatment
For associated nasal block normal saline drops in both nostrils as and when required,
especially before feeds, and use of home remedies (ginger, honey, tulsi) for control of cough
and plenty of liquids orally.To be nursed in comfortable environment.
Pharmacological treatment
 Adequate hydration and oxygenation (humidified O2) remain the backbone of treatment.
 Treatment of mild disease(ambulatory treatment at home)-No antibiotics,Syr. paracetamol
10-15 mg/kg 4-6 hourly for fever.
 If patient shows overall improvement with no evidence of chest indrawing, cyanosis,
difficulty in feeding continue treatment as above. If there is partial improvement patient


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difficulty in feeding continue treatment as above. If there is partial improvement patient
should be called again after 2 days or earlier if patient deteriorates for reassessment.
 Hospitalize immediately if any of the following develop: chest indrawing, poor feeding,
cyanosis, altered sensorium and convulsions and managed as severe disease.
 If there is no improvement or deterioration at any time during the illness, the patient should
be managed as severe disease.
 Treatment of the severe disease (needs hospitalization for management)- oxygen
administration by oxygen hood or nasal catheter and intravenous fluids if child is not able to
feed.
 Adrenaline inhalation (injectable form) 0.3 mg/kg by nebulizer after dissolving the solution


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feed.
 Adrenaline inhalation (injectable form) 0.3 mg/kg by nebulizer after dissolving the solution
in 3 ml saline; can be repeated every 4-6 hourly as required. (No role of antibiotics, steroids,
ribavirine inhalation in uncomplicated patients).
 If adrenaline not available, salbutamol inhalation (0.15 mg/kg dissolved in 3 ml soln.) may be
tried and continued if responseobserved.
 Syr. paracetamol 10-15 mg/kg dose may be given 4-6 hourly.
 Do not use sedatives.
 Monitor improvement in respiratory rate, lower chest indrawing, difficulty in feeding,
excessive crying, cyanosis and oxygen saturation, if available, every 4-6 hours till there is
significant improvement. If child does not improve/deteriorate look for underlying heart


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significant improvement. If child does not improve/deteriorate look for underlying heart
disease i.e., myocarditis/congenital heart disease and get an X-ray chest and look for massive
collapse of lung/infection/pneumothorax etc. and manageaccordingly.
Patient education
 Mother should be educated about the signs of pneumonia i.e., rapid respiratory rate, chest
indrawing, difficulty in feeding.
 Mother should be educated about identification of danger signals in a child suffering from
pneumonia and report immediately to the health care facility.
 Inhaled systemic steroids have not been recommended for the treatment of acute
bronchiolitis.


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Pediatric Conditions
383
PNEUMONIA
It is the inflammation of lung parenchyma. Pneumonia is responsible for 20% of under 5
mortalityin India. The etiological agents vary with the age of the patient. Less than three
months: Gram negative bacteria andGroup B streptococcus, 3 months to 5 yrs.S.pneumonie,
H.influenza, Staph.aureus, viruses, and >5 yearsS.pneumonie, M.pneumonie,viruses.
Salient features
Pharmacological treatment
 For non-severe pneumonia (domicillary oral treatment and follow up)
- Patients with age more than 2 months and with absence of features of severe  pneumonia can
be treated at home.
Tab/Syr. amo xicillin 20-40 mg/kg/day in 3 divided doses for 7- 10 days or Tab/Syr.
cephalexin 20-40 mg/kg/day in 3 divided doses for 5-7 days. Or chloramphenicol50-100


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cephalexin 20-40 mg/kg/day in 3 divided doses for 5-7 days. Or chloramphenicol50-100
mg/kg/day in 4 doses for 7-10 days.
- For severe pneumonia and children up to 3 months of age (Hospitalisation and IV
antibiotics.) Up to 3 months (for 7-10 days)
- Inj. cefotaxime 100 mg/kg/day 2 divided dose or Inj. cefuroxime 100 mg/kg/day in 2 divided
doses for 7– 10 days or  Inj. ampicillin 100 mg/kg/day in 3 divided doses PLUS
- Inj. gentamicin 5-7.5mg/kg/day 2 divided dose
 For severe pneumonia– age 3 months to 5 years, First line for 7 to 10 days
Inj. ampicillin IV 100 mg/kg/day in 4 divided dose or Inj. chloramphenicol 50-100
mg/kg/day in 4 divided doses
Second line-Inj. cefotaxime 150-200 mg/kg/day.
 In all age group, if staphylococcal pneumonia is suspected, treat for 14 days.


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Second line-Inj. cefotaxime 150-200 mg/kg/day.
 In all age group, if staphylococcal pneumonia is suspected, treat for 14 days.
Inj. cefotaxime/ceftriaxone  Plus cloxacillin 100-200 mg/kg/day in 4 doses.
 C lassified as mild to very severe disease.
- No pneumonia -no fast breathing and no indicators of severe or very severe pneumonia.
- Pneumonia -fast breathing e.g. age below 2 months > 60 RR/min; 2 months-12 months >
50 RR/min; 12 months-60 months > 40 RR/min and no indicatorsno indicators of severe
or very severe pneumonia.
- Severe pneumonia- lower chest indrawing or nasal flaring and no signs of very severe
pneumonia.
- Very severe pneumonia-central cyanosis or not able to breastfeed or drink or convulsions


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pneumonia.
- Very severe pneumonia-central cyanosis or not able to breastfeed or drink or convulsions
or lethargy or unconsciousness or severe respiratory distress (e.g. head nodding).
 Diagnosis: chest X ray need not be done routinely if no complication (pleural effusion, no
improvement) suspected. Children up to 3 months of age and children with severe
pneumonia are treated as in patient with parenteral antibiotics.


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Pediatric Conditions
384
Follow up and monitoring
 Mild pneumonia- reassessed at 48 hours or earlier if child deteriorates. If child shows
improvement, continued same treatment for 5-7 days. If deteriorates, patient is
hospitalized and treated as severe pneumonia.
 Children who are hospitalized (severe and very severe pneumonia) are monitored more
frequently.  Children with severe/very severe pneumonia (age >2 month) on deterioration
can be treated with cefotaxime/cefuroxime.
Patient education
 Explain the signs of pneumonia i.e., rapid respiratory rate, chest indrawing, difficulty in
feeding etc.
 Explain the danger signals in a child suffering from pneumonia.
THRUSH (ORAL CANDIDIASIS)
Salient features
Non -pharmacological treatment


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 Explain the danger signals in a child suffering from pneumonia.
THRUSH (ORAL CANDIDIASIS)
Salient features
Non -pharmacological treatment
Correctfaulty sterilization technique offeedingbottle; best to avoid bottle feeding.
Pharmacological treatment
 Clotrimazole 1%cream, gel or lotion, oral application 3-4 times/day after feeding for 5-
7days (or 1-2 days beyond recovery) Or  miconazole gel 25 mg 4 times a day for 5-7
days. Or gentian violet 1% aqueous solution 1-2 times a day, for 5-7 days (can stain
tissues and clothes).
 In resistant/chronic cases (patients with major underlying disease) Tab. fluconazole 3-6
mg/kg once daily for 5-7 days. Or Tab. ketoconazole 3-6 mg/kg once daily for 5-7 days.


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mg/kg once daily for 5-7 days. Or Tab. ketoconazole 3-6 mg/kg once daily for 5-7 days.
 In resistant recurrent/chronic thrush in a child with no obvious predisposing factor/ source
of infection, look for underlying endocrinopathy, immune disorder, AIDS and
malnutrition.
Patient education
 Emphasize on bottle hygiene, care/hygiene of the nipple and treatment of vaginal
candidiasis in expectant mother.
 Oral candidiasis may be seen as early as 7-10 days of age (peak 4th week of life)
uncommon after 12 months of age, when it is secondary to broad-spectrum antibiotic.
 Thick white patches on anerythematous base in the oral mucosa may spread to involve
the lips, buccal mucosa, tongue and palate.Asymptomatic or may cause pain in the


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the lips, buccal mucosa, tongue and palate.Asymptomatic or may cause pain in the
mouth, discomfort, anorexia and decreased feeding. Rarely may cause aspiration
pneumonia.
 Diagnosis is confirmed bythe fact that on removing the plaques, punctate areas of
bleeding are seen on the undersurface.


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Pediatric Conditions
385
CONSTIPATI ON
Salient features
Non -pharmacological treatment
 Dietary modification: Ensure adequate fluid intake in diet. In infants, breast milk should
continue as it is less likely to be constipating than cow's milk, can add extra sugar in
cow's milk if child is not breast-fed.
 Add fiber by cereals (wheat bran, oat), pulses, vegetables, salads and fruits and isabgol.
 Toilet training to achieve regular evacuation. Child is instructed to use bathroom after
breakfast or dinner, to take advantage of meal stimulated increase in colonic motility.
 Maintain calendar to record evacuations.
 Positive reinforcement (reward/appreciation) for successful toileting (no punishment for
failure).
Pharmacological treatment


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 Positive reinforcement (reward/appreciation) for successful toileting (no punishment for
failure).
Pharmacological treatment
 Agarol or lactulose in infants 2.5-10 ml/day; children 40-90 ml/day in 3 -4
divided doses.  Or  mineral oil (liquid paraffin) 5-15 ml/kg/day Or milk of magnesia 0.5-3
ml/kg/day. Dose is titrated to produce at least one stool/day.
 Enemas may be used in severe cases where sufficient trial of medical therapy
has failed. To empty the bowel of faecoliths, enemas may be required daily or on
alternate days for initial few days.
 In severe cases with faecal soiling, in the initial stages: bowel cleaning/ disimpaction may
be required with enemas 1-2/day or suppositories 1-2/day. In very severe cases with


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be required with enemas 1-2/day or suppositories 1-2/day. In very severe cases with
multiple faecoliths, failed medical treatment, mental retardation etc., surgical
disimpaction may be done.
 If a surgical cause is suspected patient should be investigated and treated accordingly.
The main objective of medical management is to dislodge faecal mass, overcome
withholding behaviour and promote regular bowel habits.
 D efined as the passage of hard stools that are difficult to pass irrespective of frequency.
However, passage of stool less than twice a week is considered asconstipation.Genuine
hard stools may result from an inadequate milk intake, hunger stools, use of over-
strength artificial feeds and low roughage diet.


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hard stools may result from an inadequate milk intake, hunger stools, use of over-
strength artificial feeds and low roughage diet.
 True constipation may be due to imperforate anus, meconium plug, low intestinal
obstruction, Hirschsprung's disease, or hypothyroidism but most of the time it is
idiopathic.
 Symptoms include fretfulness, poor appetite, intermittent abdominal pain, distension.
Retentive posturing occurs with urge to defaecate, relieved after going to the toilet.
There maybe history of recurrent UTI. Weight gain may be impaired.


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Pediatric Conditions
386
Patient education
 Importance of dietary modifications should be explained. Treatment should not be
abandoned early after recovery.
 Bowel training should have only positive reinforcements. Negative reinforcement should
be avoided at all costs.
ACUTE DIARRHOEA
Salient features
The following table lists the investigations that may be done if indication exists.
Table 9. Investigationsin acute diarrhoea
Investigations Indications
Stool microscopy Dehydration or high fever, Diarrhoea persisting beyond 7
days, blood persisting in stool after 48 hour, of treatment
Blood urea,
S. electrolytes (SE) and
arterial blood gas (ABG)
All 3 investigations in moderate to severe dehydration, SE in
persistent vomiting or signs of dyselectrolytaemia, ABG in


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arterial blood gas (ABG)
All 3 investigations in moderate to severe dehydration, SE in
persistent vomiting or signs of dyselectrolytaemia, ABG in
respiratory distress and no chest signs and sepsis (correct it
only if pH <7.25).
Infection screening by
TLC, DLC, band cell count,
ESR and CRP
Fever persisting >72 hours, PEM > grade III or age <3
months.
Blood culture Suspected sepsis, Before starting antibiotics.
Chest X-ray, CSF and othersAs and when required
Stool culture No role
Non -pharmacological treatment
 Maintain hydration by homeavailable fluids (HAF) in place of or along with ORS. These
are rice, kanji, butter milk, dal soup, coconut water or weak tea etc. Soft drinks,
sweetened fruit drinks and tea are unsuitable and could be potentially dangerous.


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sweetened fruit drinks and tea are unsuitable and could be potentially dangerous.
 Acute diarrhoea is defined as passage of 3 loose stools per day for duration of less than
7 days, and increased fluidity or volume of stools. It is caused commonly byRotavirus,
E. coli, V. cholerae, Giardiaor parenteral infections and invasive diarrhoea byShigella,
Salmonella and E. histolytica.
 Clinical features of diarrhoea are frequent stools, vomiting, fever and dehydration.
 Dehydration is categorized into some dehydration and severe dehydration.In some
dehydration child is thirsty and drinks voraciously, active and alert but irritable, with
sunken eyes, depressed fontanelle, absent tears, loss of skin turgor and some decrease in


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sunken eyes, depressed fontanelle, absent tears, loss of skin turgor and some decrease in
urine output. In severe dehydration all these are more severeexcept that child is
lethargic and does not want to drink water.


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Pediatric Conditions
387
 Maintain nutrition: continue breast feeding. Continue normal light diet e.g. khichri, dalia,
banana or mashed dal etc. Do not dilute or stop milk as there is not much role of lactose
intolerance or milk protein allergy. Give extra food during recovery.
Pharmacological treatment
 Low osm olarity oral rehydration solution (ORS) is used in some dehydration 75 ml/kg in
4 hours under observation.
 After 4 hours if dehydration is corrected, or if child was not dehydrated at presentation,
send home with instructions to give ORS in 2:1 dilution asaccepted by the child. Asked
to report back if vomiting persists or urine is not passed for >8 hours. As a rough
guideline 10 ml/kg of ORS may be added for each large stool.


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to report back if vomiting persists or urine is not passed for >8 hours. As a rough
guideline 10 ml/kg of ORS may be added for each large stool.
 If dehydration is not corrected after 4 hours, same amount of ORS may be repeatedin
next 4 hours and if dehydration is corrected, send the patient home. If dehydration does
not improve in 8 hours or if it worsens, abandon oral rehydration therapy (ORT) and give
IV fluids.
 Zinc ORS is not superior to supplementation of zinc separately,in malnourished children
with diarrhoea.
 Principles of Oral Rehydration Therapy (ORT)
- Give in small sips.
- Vomiting is not a contraindication unless persistent.
- Contraindicated in altered sensorium or paralytic ileus.
- Stop as soon as diarrhoea stops.


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- Vomiting is not a contraindication unless persistent.
- Contraindicated in altered sensorium or paralytic ileus.
- Stop as soon as diarrhoea stops.
 IV fluid therapy in case of severe dehydration or shock or contraindications or
failure of ORT. N/2 saline is given over 8 hours (1:100 ml KG after child passes
urine), as follows:
- Some dehydration-75 ml/kg.
- Severe dehydration-100 ml/kg (half in first 2-3 hours)
- Shock-push 20 ml/kg of Ringer's lactate or normal saline over 15 minutes and can repeat
twice more if shock persists use central venous pressure monitoring for further
management if shock present after pushing 60 ml/kg.
 Specific therapyis indicated-Frank blood and mucus in the stool or >10 pus cells/HPF


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management if shock present after pushing 60 ml/kg.
 Specific therapyis indicated-Frank blood and mucus in the stool or >10 pus cells/HPF
- Syr. ciprofloxacin 15-20 mg/kg/day in 2 divided doses (Shigella strains are largely
resistant to ampicillin and cotrimoxazole) for 5 days
Giardiasis (only if trophozoites are seen on stool microscopy)
- Syr. metronidazole 15 mg/kg/day in 3 divided doses for 5 days Or
- Syr. tinidazole 50 mg/kg/day single dose (max. 2 g)
Cholera (suspect in any child with severe watery diarrhoea)
Mainstay of treatment is fluid therapy and following antibiotic may be usedto prevent
spread:Syr. doxycycline 5 mg/kg (max 200 mg) in single dose. OrSyr. furazolidone 5
mg/kg/day in 4 divided doses for 3 days. OrSyr. cotrimoxazole (TMP) 8 mg/kg/day in 2


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mg/kg/day in 4 divided doses for 3 days. OrSyr. cotrimoxazole (TMP) 8 mg/kg/day in 2
divided doses for 5 days. OrSyr. erythromycin 30 mg/kg/day for 3 days.


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Pediatric Conditions
388
 Severe infections to be treated by appropriate parenteral antibiotics.
 There is not much role of antiemetics in a child with vomiting. Rule out meningitis, URI
and dyselectrolytaemia and give ORS in sips. If vomiting persists give intravenous fluids.
Howeve r, occasionally 1 or 2 doses of metoclopramide (0.5 mg/kg) or domperidone (0.5
mg/kg) may be tried before giving intravenous fluids. Binding agents e.g., Kaolin pectin
etc. are not useful.
 Following drugs are contraindicated,
- Antimotility agents e.g. diphenoxylate, atropine etc.and antisecretory agents e.g.,
loperamide, salicylates etc.
 Keep record of vitals e.g. pulse, BP, capillary filling time (CFT), respiratory rate (1


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loperamide, salicylates etc.
 Keep record of vitals e.g. pulse, BP, capillary filling time (CFT), respiratory rate (1
hourly) and temperature (6 hourly). Monitor for improvement or worsening of signs of
dehydration. Record urine output and stool frequency and consistency.
 Modifications or step up treatment
- Admit if PEM grade III or age <3 months (as higher chances of complications e.g. shock,
hypoglycaemia etc.), associated severe systemic infections e.g. septicaemia, meningitis or
pneumonia.
- Investigate for lactose intolerance, incipient infections e.g., Urinary tract infection (UTI)
or rare gut organisms, if diarrhoea persists for >7 days.
- Exclude parenchymal renal failure, if child has not passed urine after hydration. Give a


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or rare gut organisms, if diarrhoea persists for >7 days.
- Exclude parenchymal renal failure, if child has not passed urine after hydration. Give a
fluid challenge (20 ml/kg of normal saline) followed by frusemide injection (1-2 mg/kg).
If urine is still not passed then parenchymal renal failure considered and managed
accordingly.
Patient education
 Inform natural course of diarrhoea to avoid dissatisfaction and ORS only prevents
dehydration i.e. purge rate and consistency usually improves by 3-7 days
 Explain the complications in diarrhoea are because of dehydration and thus ORS is the
mainstay of therapy. Explain preparation of ORS and method of administration.
Nutritional advice as mentioned earlier in non-pharmacological section. Education about
food and water hygiene.


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Nutritional advice as mentioned earlier in non-pharmacological section. Education about
food and water hygiene.
ACUTE VIRAL HEPATITIS
Itis a systemic infection affecting liver and is caused by Hepatitis A, B, C, D, E viruses etc.
Commonest causes for infective hepatitis among children are Hepatitis A and Hepatitis E.
Both of these are spread by faeco-oral route. Hepatitis B and C are more common in children
receivingblood product for certain chronic illnesses.
SalientFeatures
 Prodrome constituted by fever, malaise, nausea, emesis, anorexia and abdominal
discomfort may precede the appearance of jaundice. It may go unnoticed or may be
severe mimicking malaria ortyphoid fever.


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Pediatric Conditions
389
Non -pharmacological treatment
 Rest if the patient feels exhausted or fatigued (forced rest does not help and does not
shorten the time to recovery).
 Regular small frequent meals with high caloric content. High carbohydrate diets are
acceptable but should be hygienic. Traditionally sugarcane juice is used as home therapy
though it has no established benefit.Maintain adequate hydration in case of vomiting and
avoid fatty meals.
Pharmacological treatment
 There is no specific treatment for simple acute viral hepatitis. Uncomplicated cases can be
treated at home.If patient has frequent vomiting, oral metoclopramide 0.1 mg/kg/dose
can be given as and when required but not to be repeated before 6 hours.


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can be given as and when required but not to be repeated before 6 hours.
 Usually fever abates after jaundice appears.Occasionally if the situation requires,
paracetamol may be used sparingly.
 Persistent high grade fever suggests alternative diagnosis. Hospitalization required only in
clinically severe illness e.g. alteration in sleep pattern, altered behaviour, abnormal
movements, persistent vomiting, dehydration, decreased urinary output, bleeding from
any site or any other complication.
Patient education
 Continue breast feeding or other regular feeding.Observe carefully for any danger signs
listed above.Usually a selflimiting disease and fever subsides after the jaundice is
evident clinically. Most patients start recovering in 7-14 days time. Total duration of
illness is 3 weeks.


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evident clinically. Most patients start recovering in 7-14 days time. Total duration of
illness is 3 weeks.
 Hepatitis A and B are two different diseases. Getting your child vaccinated with hepatitis
B vaccine will not protect you against Hepatitis A.Hepatitis A spreads through
contaminated food and water and close person to person contact.
 Raw or insufficiently cooked food (fruits, vegetables, salads) or cooked food handled by
an infected individual can be the source of hepatitis A infection.
CHICKENPOX OR VARICELLA
Varicella is the primary infection caused by varicella-zoster virus. It is highly infectious and
is transmitted by droplet infection. The incubation period is about 14 days.
Salient features
Non pharmacological treatment


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is transmitted by droplet infection. The incubation period is about 14 days.
Salient features
Non pharmacological treatment
 Begins as crops of small red papules over the trunk appearing within 1 day of fever and
systemic symptoms which quickly develop into clear, often oval vesicles on an
erythematous base. Contents becomecloudy in about 24 hours and then scab. Many
such crops may appear for 3-4 days.
 Bacterial superinfection, thrombocytopenia, arthritis, hepatitis, encephalitis or
meningitis can complicate the disease.The disease is severe in adolescents and adults
as well as immune compromised individual. Reactivation disease results in herpes
zoster or shingles.


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Itching is bothersome and scratching effect may be minimized by making the patient wear
mittens. Daily change of clothes and good personal hygiene may decrease the risk of
secondary infection.
Pharmacological treatment
 For management of fever: Aspirin and other salicylates are contraindicated due to risk of
Reye's syndrome and should not be used.
 Local anti-pruritic agents like calamine lotion may alleviate itching. If itching is not
relieved with above. Tab. pheniramine 25 mg 2 times a day Or Tab. cetirizine: in
children (2-6 years) 5 mg; (>6 years) 10 mg once a day.
 In case of immuno-compromised children on long term treatment with steroids, anti-
cancer drugs or other immunosupressive therapy, HIV positive patients, children older


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cancer drugs or other immunosupressive therapy, HIV positive patients, children older
than 12 years of age, those with chronic cutaneous or pulmonary disorders who are at
increased risk of severe disease, oral acyclovir if started within few hours (<24 h) of the
onset of rash may decrease the duration, magnitude of feveras well as the number of skin
lesions.
 Tab. acyclovir 20 mg/kg/ day is given 6 hourly for 5 days. In case the patient is severely
immuno -compromised or severe disease in adults, Inj. acyclovir should be started as soon
as possible in all cases at the doseof 10 mg/kg 8 hourly IV for 7 days.
Assessment of response to therapy
 Most cases will stop having fever after the initial 3-4 days when new crops of vesicle stop


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Assessment of response to therapy
 Most cases will stop having fever after the initial 3-4 days when new crops of vesicle stop
appearing. The vesicles normally heal by scabbing in about a week's time. Persistence of
fevermay suggest secondary infection.
Patient education
 The disease is self limiting in healthy children. Child should be excluded from day care or
school till after 6th day of the rash or till scabs are formed.
 Do not uses “over the counter” fever medicines a s they may contain aspirin or other
salicylates.
 An expensive but potent vaccine is available for protection against the disease and can be
recommended only for those at risk of severe form of the disease and are
immunocompetent.
 Post exposure prophylaxiswith Varicella Zoster Immunoglobulin (VZIG, specific


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immunocompetent.
 Post exposure prophylaxiswith Varicella Zoster Immunoglobulin (VZIG, specific
immunoglobulin) is recommended for the contacts that are severely immunocompromised
or pregnant (particularly in the first trimester).


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Pediatric Conditions
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MEASLES
Salient features
Non -pharmacological treatment
 Isolate from others particularly unimmunized children for at least four days after the
appearance of the rash.
 Bed rest and cold sponging may be required for febrile patients.
 Small frequent feeds and plenty of oral fluids should be continued.
Pharmac ological treatment
No specific antiviral treatment is available. Fever is managed with oral paracetamol.
Treatment of other co-existing problems
 Inj. vitamin A 100,000 IU or high dose oil based oral preparation (50,000 IU) is given IM
for 2 consecutive days. A third dose may be given 4 weeks later particularly if there are
manifesting signs of vitamin A deficiency.
 Treat appropriately secondary bacterial infection like bronchopneumonia and or


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manifesting signs of vitamin A deficiency.
 Treat appropriately secondary bacterial infection like bronchopneumonia and or
gastrointestinal infection.
Patient education
 The disease leads to marked anorexia and also often precipitates protein energy
malnutrition (PEM) and other deficiencies. Regular frequent feeds must continue. Extra
meal should be added during convalescence.
 The disease usually lasts 10-12 days and the maximum risk of infectivity is 5 days prior
to and 4 days after the appearance of rash. The rash usually heals by desquamation and
often leaves some hyperpigmented stains on the body which disappears over weeks
subsequently.
 The parents must report to the hospital in case thechild develops any of the following
warning signs:


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subsequently.
 The parents must report to the hospital in case thechild develops any of the following
warning signs:
- Stiff neck, convulsions (seizures), extreme drowsiness, loss of consciousness or altered
behaviour.
- Rapid and or laboured breathing, difficulty in feeding, cyanosis.
- Significant dehydration as evident bysunken eyes or fontanelles, loss of skin turgor,
dryness of tongue or lack of tears etc.
- Blood in stools.
 It is characterized by fever, cough, coryza, conjunctivitis, an erythematous
maculopapular rash appearing on the 4th day of the illness, and a pathognomonic
enanthem (Koplik spots).Rash starts from behind the ears, along the hairline, involve
the face and then the trunk and the limbs.


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enanthem (Koplik spots).Rash starts from behind the ears, along the hairline, involve
the face and then the trunk and the limbs.
 Fever usually subsides after the appearance of the rash unless there is some
complication such as otitis media, bronchopneumonia, laryngotracheobronchitis
(croup), and diarrhoea. Acute encephalitis, which frequently results in permanent brain
damage, occurs in approximately 1 in every 1000 cases.


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 Vaccination against measles is recommended at 7- 9 months of life and a subsequent
booster with measles or MMR is mandated at 15 months of age particularly if the primary
immunization was done at less than 9 months of age. There is no role of giving measles
vaccination to a child who has already suffered from the disease.
 Unimmunized child below 5 year  in contact with the patient may be immunized. Measles
vaccine, if used early, can prevent or decrease the severity of the disease in the secondary
contacts.
MUMPS
Mumps is a disease caused by a virus that can infect many parts of the body, especially the
parotid salivary glands.
Salient features
Non -pharmacological treatment


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parotid salivary glands.
Salient features
Non -pharmacological treatment
 Child should be encouraged to drink plenty of fluids. Water, decaffeinated soft drinks and
tea are better tolerated than acidic fruit juices (like orange juice, grape fruit juice or
lemonade) that make parotid pain worse.
 Either warm or cold packs- whichever feels better- may be used to sooth the swollen
parotid glands.
Pharmacological treatment
 Most cases are treated symptomatically on OPD basis.
 Fever treated using non aspirin fever medications such as paracetamol (10-15 mg/kg/day
SOS or every 4-6 hours). These medicines will also help relieve pain in the swollen
parotid glands. (caution: aspirin is contraindicated in children with viral illnesses due to
risk of Reye's syndrome).


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parotid glands. (caution: aspirin is contraindicated in children with viral illnesses due to
risk of Reye's syndrome).
 Being a viral illness, antibiotics have no role. There is no specific therapy available.
 Patients with abdominal pain, testicular swellings or signs of raised intracranial tension
need to be admitted in the hospital.
Patient education
 Parents should be explained warning signs e.g. in boys, parents are told to watch for high
fever, with pain and swelling of the testicles.
 The parotid glands become swollen and painful over a period of one to three days.
There is often a fever of up to 103°F (39.4oC), with headache and loss of appetite.
 Mumps can also involve the brain, pancreas and other organs. The involvement of these


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 Mumps can also involve the brain, pancreas and other organs. The involvement of these
organs signifies a severe disease and there is usually a recrudescence of high fever in
such situations in addition to organ specific symptoms.
 Meningoencephilitis is the commonest complication (250/100 000 cases). Other
complications are orchitis, epididymitis, oophritis, pancreatitis, thyroiditis, myocarditis,
deafness, optic neuritis and arthritis.


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 Watch for abdominal pain that can mean involvement of the pancreas in either sex, or
involvement of the ovaries in girls.
 Severe headache, stiff neck, convulsions (seizures), extreme drowsiness etc suggest CNS
involvement and need for admission to a tertiary level center.
 Recurrence of high grade fever (above 101°F/38.3°C) often heralds onset of the above
complication and can be used as an early referral sign.
 Children usually recover from mumps in about 10-12 days. First attack of mumps almost
always gives lifelong protection against another, therefore, such children do not benefit
from any immunization later.
 Mumps can be prevented by a vaccine which can be given alone, or as partof the mumps-


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from any immunization later.
 Mumps can be prevented by a vaccine which can be given alone, or as partof the mumps-
measles-rubella (MMR) vaccine given at the age of 15 months. Mumps vaccine is
effective in 75 to 95% of immunized persons.
ACUTE FLACCID PARALYSIS
Acute Flaccid Paralysis (AFP) isdefined as any child aged <15 years, with acute onset of
flaccid paralysis without any obvious cause (e.g. severe trauma or electrolyte imbalance like
hypokalaemia). AFP is a notifiable disease and all cases must be reported to Nodal Officer
and District Surveillance Officer, NPSP Unit, Directorate of Family Welfare.
Salient features
Treatment for acute polio cases
All cases should be treated as below except patients with isolated single lower limb


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Salient features
Treatment for acute polio cases
All cases should be treated as below except patients with isolated single lower limb
involvement and reporting after 4 days of onset of paralysis and currently not progressing for
more than 48 hours.
Non -pharmacological treatment
 Complete bed rest and correct positioning of the affected limbs in the optimal position as
follows: Hip- slight flexion, knee- 5 degrees flexion, foot- 90 degrees with support
against the soles. Both legs should be supported from the lateral sides with pillows or
rolled towels or salt/sand packs to prevent rotation.
 When pain subsides, passive movements of the joints for about 10 minutes, 2-3 times a
day.
 Warm water fomentation using hot packs with soaked towels wrapped around the affected


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day.
 Warm water fomentation using hot packs with soaked towels wrapped around the affected
parts for about 10 minutes, 2-3 times a day help in relieving pain.If transient urinary
retention occurs, alternate hot and cold compresses over the suprapubic region.
Caution: No massage or intramuscular injections as it may further precipitate paralysis.
Watch for progression, particularly for the involvement of the respiratory muscles.
 The paralysis is of acuteonset (<4 weeks) and the affected limb(s) are flaccid (floppy
or limp). If the AFP is due to polio, then sensation is never affected.
 Pseudoparalysis due to pain in osteomyelitis, abscess, scurvy, unrecognized trauma
leading to contusions, slipped epiphysis or fractures etc can also mimic AFP.


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Pharmacological treatment
There is no specific drug therapy for polio. For fever and pain, use paracetamol or ibuprofen.
Referral to a tertiary care level center with a ventilatory support facilities if there is
progression of paralysis, respiratory distress, bulbar involvement, paralysis of upper limbs
which is <3 days old (there is higher risk of diaphragmatic involvement in such cases),
marked drowsiness or any other complication.
Patient education
 No dietary restrictions, however, continue breast feeding or other regular feeding.
 Paralysis progresses usually for about 4-7 days after onset. Recovery may start thereafter
over days to weeks with little recovery of strength after 6 months of illness. A regular


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over days to weeks with little recovery of strength after 6 months of illness. A regular
physiotherapy facilitates recovery of muscles. Note: Post polio residual paralysis should
be referred for rehabilitative services to an appropriate centre.
PERTUSSIS (WHOOPING COUGH)
The causative organism isBordetella pertussiswhich leads to this respiratory disorder.
Salient features
Pharmacological treatment
 Syr./Tab. erythromycin, 40-50 mg/kg/day in 4 divided doses orally for 14 days initiated
early in the coryzal phase of the disease i.e. first 14 days of the illness may shorten the
course of whooping cough, which otherwise may last for weeks or months. Once the
paroxysms start, no antimicrobial have any benefit except for eradication of any
secondary pulmonary infection.


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paroxysms start, no antimicrobial have any benefit except for eradication of any
secondary pulmonary infection.
 In patients with severe coughing paroxysms salbutamol 1-2 mg/kg/ day in 3-4 divided
doses for a week or so may be tried.
 Severe cases particularly those <6 months of age and those with respiratory distress need
to be admitted for intravenous fluids and oxygen therapy.
Supportive therapy
 Oxygen therapy is required in severe cases with respiratory distress. Hydration should be
maintained with intravenous or oral fluids in adequate amounts (cough suppressants are
usually not helpful).
Patient education
 To continue feeding during the prolonged period of cough, adequate hydration and
nutrition to prevent onset of malnutrition.


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Patient education
 To continue feeding during the prolonged period of cough, adequate hydration and
nutrition to prevent onset of malnutrition.
 Beginning as a mildURTI (catarrhal stage), can progress to severe paroxysms of
cough, often with a characteristic whoop, followed by vomiting.
 The child runs out of breath with bulging eyes, flushed face,lacrimation. salivation,
protrusion of tongue and distension of the neck veins etc. Such episodes are
exhausting and precipitated by yawning, sneezing andeating.


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Pediatric Conditions
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 Antibiotic therapy must be continued for at least 14 days to prevent relapse of the disease,
even if they may not be providing any relief in the symptoms. All contacts below 7 years
of age must be given erythromycin for 14 days.
 Contact the doctor immediately if the patient develops listlessness, apnoea or seizures.
This is particularly more common in infants below 6 months.
 Immunization against pertussisis as triple antigenDiphtheria Pertussis Tetanus(DPT)
and 3 primary doses are routinely advised for all infants followed by a booster after 1.5
years and 4.5 years after the primary immunization.
CARDIAC FAILURE
Cardiac failure is defined as a state in which the heart cannot deliver an adequate cardiac


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CARDIAC FAILURE
Cardiac failure is defined as a state in which the heart cannot deliver an adequate cardiac
output to meet the metabolic needs of the body. Clinical presentation is dependent on age and
degree of cardiac reserve. Common causes according to age of presentation are:  Neonate-
Severe anaemia, heart block, congenital heart disease e.g. hypoplastic left heart, coarctation,
left to right shunt and large mixing cardiac defects.Infant– Left to right shunt,
supraventricular tachycardia Children– Rheumatic fever, myocarditis, cardiomyopathy, acute
hypertension.
Salient features
Non -pharmacological treatment
 Restricted activity and bed rest with upright posture depending on cardiac reserve.
 In severe CHF, dietary modifications in infants by increasing calories per feed. Breast-


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 In severe CHF, dietary modifications in infants by increasing calories per feed. Breast-
feed supplementation, naso-gastric feed to avoid the exertion of active feeding.
 No added salt in diet and fluid restriction. Cold sponging in case of fever.
Pharmacological treatment
Identify and treat the underlying cause.  Algorithm for treatment is shown in figure.
 Elixir/Tab. digoxin (Elixir 0.25 mg/5 ml, Tab. 0.25 mg)
Method of digitalization: 0.5 x digitalization dose initially, 0.25 x digitalizing dose 8 and 16
hours later.
Digitalizing dose: Newborn = IV, IM: 0.010- 0.030 mg/kg divided or orally: 0.040 mg/kg
divided in fractions.
Infants = IV, IM 0.030-0.040 mg/kg or orally 0.050 mg/kg in fractions.
Children = IV, IM, PO: 0.010-0.015 mg/kg in fractions.


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divided in fractions.
Infants = IV, IM 0.030-0.040 mg/kg or orally 0.050 mg/kg in fractions.
Children = IV, IM, PO: 0.010-0.015 mg/kg in fractions.
 Exertional dyspnoea, poor weight gain, feeding difficulties,fast breathingwith
improvementwhen upright, persistent cough and wheezing, excessive perspiration and
irritability, puffiness of face and pedal oedema.
 Tachypnoea, tachycardia, small volume pulse, peripheral cyanosis, pedal/facial/ sacral
oedema, hepatomegaly, raised JVP (appreciated well inolder children), gallop rhythm,
cardiomegaly and failure to thrive.


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Pediatric Conditions
396
 M aintenancedosage 24 hours after 1st fraction of digitalizing dose. Newborn = PO: 0.005
- 0.010 mg/kg/24 hours, divided every 12 hours. In infants and children orally 0.002-
0.005 mg/kg/24 hours divided every 12 hours.(Caution: Avoid hypokalaemia during
therapy with digoxin)
 Tab. furosemide 1 -2 mg/kg every 12 hourly (may need K supplement).
Or  Tab. chlorothiazide 20-50 mg/kg/day in 2 divided doses. Or Tab. spironolactone 1-3
mg/kg/day in 2 divided doses.
 In cases with regurgitant cardiac lesions like severe MR where reduction
in after load is required, Tab. captopril 0.1-0.2 mg kg/dose 8-12 hourly (maximum 4
m g/kg/day). Or  Tab. enalapril 0.08-0.5 mg/kg/dose 12-24 hourly (maximum 1 mg/kg/
day).


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m g/kg/day). Or  Tab. enalapril 0.08-0.5 mg/kg/dose 12-24 hourly (maximum 1 mg/kg/
day).
 Patients with hypotension and low cardiac output should be referred to a higher center for
Inj. dopamine infusion (40 mg/ml) 2-20 mcg/kg/min prepared in normal saline or 5%
dextrose. Hypovolaemia should be corrected before infusion is started and BP is
monitored during the infusion. Or Inj. dobutamine infusion (250 mg/5 ml) 2- 20
mcg/kg/min. Both the drugs can be used simultaneously to have added response.
Patient education
 Decreased salt intake, sufficient rest and adequate sleep must be emphasized. Strict bed
rest is necessary only in severe cases. Semi-upright position during sleep may make the
patient more comfortable.
Figure 1. Algorithm for treatment of congestive cardiac failure


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Pediatric Conditions
397
DIABETES MELLITUS
Salient features
Diagnosis
Table shows the cut off levels of plasma glucose used for diagnosis of DM, while doing oral
glucose tolerance test (GTT)-after glucose dose of 1.75 g/kg of ideal bodyweight (maximum
75 g).
Table 10. Cut off levels of plasma glucose for diagnosis of diabetes mellitus
Impaired glucose tolerance Diabetes mellitus (DM)
Fasting glucose 110-125 mg/dl * Symptoms of DM plus random plasma
glucose >200 mg/dl
2 h plasma glucose during theOr
OGTT <200 mg/dl but < 140 mg/dl
Fasting plasma glucose >126 mg/dl
Or 2 h plasma glucose during the OGTT#
>200 mg/dl
* Symptoms include polyuria, polydipsia & unexplained weight loss with glycosuria and
ketonuria # OGTT Oral glucose tolerance test
Non -pharmacological treatment
 Diet:


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ketonuria # OGTT Oral glucose tolerance test
Non -pharmacological treatment
 Diet:
- Regularity of eating pattern is very important so that diet and insulin dosing is
synchronized.
- General nutritional guidelines are followed. Calorie mixture should have 55%
carbohydrates, 30% fat and 15% proteins.
- Avoid carbohydrate with refined sugars to prevent metabolic swings. Carbonated drinks
should be of sugar free variety.
- Fats derived from animal sources to be reduced and should be replaced by fats of
vegetable origin.
- Calorie intake should be split as 20% breakfast, 20% lunch, 30% dinner and 10% each for
3 snacks at mid morning, mid afternoon and evening.
 Physical activity and fitness:
- Usual exercises advised to diabetic children and adolescents include vigorous walking,


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 Physical activity and fitness:
- Usual exercises advised to diabetic children and adolescents include vigorous walking,
jogging, swimming, tennisetc.
 Most cases of DM in children are of insulin dependent diabetes mellitus (IDDM)
and have hyperglycaemia with glucosuria.While some present with classical
symptoms of polyphagia, polydipsia, polyuria and weight loss, many children at the
onset present in the state of diabetic ketoacidosis (DKA).
 Diagnosis is made by demonstration of hyperglycaemia (random plasma glucose
more than 200 mg/dl).Patients during DKA have moderate to severe dehydration
with plasma glucose levels usually more than 300 mg/dl, metabolic acidosis,
ketonuria and various electrolyte disturbances.


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- Though, diabetics can undertake any exercise, but unusual exercise may require modification
in insulin dosing. For the schedule day of unusual exercise, insulin dose may be reduced by
10-15%.
Pharmacological treatment
 Initial therapy:
Treatmentis initiated in the hospital with fast acting (regular) insulin. At the onset of DM
(or after recovery from DKA) the dose of insulin is 0.5-1.0 unit/kg/day.
Inj. Regular insulin 0.1-0.25 units/kg subcutaneous injections are given 6-8 hourly before
me als.
- Simultaneous blood glucose level monitoring is done. One to two days therapy is required
to find out total daily insulin requirement. Once the patient stabilizes on 6 hourly insulin
injections, the patient is switched over to "2 daily injections" schedule.


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injections, the patient is switched over to "2 daily injections" schedule.
- In "2 daily injections" schedule, the insulin is administered as follows:
Combinations of intermediate acting (usually lente) insulin and fast acting (regular)
insulin in the ratio of 2-3:1. Two third of total daily-dose is injected before breakfast and
one third before dinner. Each injection has combination of both types of insulin e.g., total
dose of insulin is 30 units-20 units (14 units lente and 6 units regular) are injected before
breakfast and 10 units (6 units lente and 4 units regular)are injected before dinner.
- Blood glucose levels are monitored before each meal and the dose of insulin adjusted
accordingly. Blood glucose levels should ideally be 80 mg/dl fasting and 140 mg/dl after


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accordingly. Blood glucose levels should ideally be 80 mg/dl fasting and 140 mg/dl after
meals (acceptable range between 80-240 mg/dl). Earlymorning 3 AM blood glucose
level should be more than 70 mg/dl.
 Modification in the insulin doses:
- Modification in the insulin doses will be required depending upon the blood glucose
levels. Any increase or decrease in insulin dose is by 10-15% (generally not more than 6
units).
- After initial stabilization, newly diagnosed cases may have gradual decline in insulin
requirement even upto 0.5 units/kg/day. This may persist for several weeks to several
months.
- Decrease total dose of insulin by 10% at the timeof discharge from hospital as the
increased activity at home will decrease the insulin requirement.


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increased activity at home will decrease the insulin requirement.
 Assessment of diabetic control or response to therapy
- Blood glucose estimation should be done before each meal and at bed time in the first few
weeks afterdiagnosis. After stabilization, it can be reduced to twice a week.
- Periodically blood glucose estimation at 3-4 AM is required to detect early morning
hypoglycaemia.
- Urine for sugar is also monitored initially 3-4 times daily before meals. Urine for ketones
once daily should be done.


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- Glycosylated haemoglobin (HbA1c estimation-once every 3 months.- levels of 6-9%
represent very good control of diabetes, 9-12% show fair control and above 12%
represent poor control.
- Serum lipids-cholesterol, HDL, LDL, VLDL, triglycerides and urine for protein should
be done once every year. Serum cholesterol should be less than 200 mg/dl, LDL less than
130 mg/dl and triglycerides less than 140 mg/dl.
- Thyroid function tests should be done once every year to detect concomitant
hypothyroidism.
Patient education
 Patient/parents should be taught self diabetic care which should include:Technique of
measuring insulin in the syringe. Importance of drawing insulin always in the same


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measuring insulin in the syringe. Importance of drawing insulin always in the same
sequence (usually regular insulin first) so thatsame type of insulin is left over in the dead
space of the syringe. Explain technique of subcutaneous injections and importance of
rotating the injection sites-arms, thighs (upper and lower), buttocks and abdomen.
 Adherence to diet and regular exercise.Recognizing the symptoms of hypoglycaemia and
its home management.
HYPOTHYROIDISM
Salient features
Pharmacological treatment
 Thyroxin treatment should be started as soon as the diagnosis has been confirmed by thyroid
function tests (preferablythe same day as the evaluation).
 There remains some controversy regarding the initial starting dose of thyroxin and how


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function tests (preferablythe same day as the evaluation).
 There remains some controversy regarding the initial starting dose of thyroxin and how
quickly the Thyroid stimulating hormone (TSH) should be normalized. A recommended
starting dose is approximately 10-15 mcg/kg/day.
 The initial dose for first 7 days may be on the higher end (14 mcg/kg/day) and then reduced
to lower level (10 mcg/kg/day) and then tapered to 5-7 mcg/kg/day by 1styear.
 Most cases in children are due to congenital hypothyroidism causes such as aplasia,
hypoplasia or ectopia of thyroid gland. Common causes of acquired hypothyroidism are
iodine deficiency, lymphocytic thyroiditis and following irradiation of cervical region
for malignant disorders.


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iodine deficiency, lymphocytic thyroiditis and following irradiation of cervical region
for malignant disorders.
 The diagnosis is quite often missed in the initial months; hence neonatal screeningis
important.The diagnosis is based on demonstration of low serum T4. Serum T3 levels
may be normal and are not useful for diagnosis. In primary hypothyroidism, TSH is
elevated. Radionuclide scans are not essential for diagnosis but help to delineate the
exact etiology.


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400
Table 11. Guideline for dosage of L-thyroxinein children
Age Dose in (mcg/kg/day)
0-6 months 8-15
6-12 months 7-10
1-5 years 5-7
5-10 years 3-5
10 -12 years 2-4
Assessment of response
 Early response is evident in initial few weeks withsymptomatic improvement in
alertness, relief of constipation, improvement in appetite and feeding.Increased linear
growth and osseous maturation is seen over next few months.
 The child should be followed clinically every month for 6 months, 3 monthly till 2 years
and thereafter once to twice every year. Recurrence of symptoms such as lethargy,
constipation and weight gain suggest under treatment and diarrhoea, palpitations,
increased appetite and weight loss suggest overdosing.Periodic check on thyroid


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increased appetite and weight loss suggest overdosing.Periodic check on thyroid
function tests is needed (6 monthly or so). Serum T4 level should be maintained in upper
normal range and TSH levels suppressed to normal.
 After few months of starting therapy, sometimes features suggestive of raised intracranial
tension such as headache and vomiting may appear. The patient should be immediately
admitted and treated.
Patient education
 N eed for life long administration of the drug.Regular follow up at the interval described,
important for proper monitoring and dose titration.
 Clinical symptoms of under or overdosage, including the danger signs of pseudotumour
cerebri should be explained.In infants, thyroxine should be given by crushing the tablet


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cerebri should be explained.In infants, thyroxine should be given by crushing the tablet
with little milk or water, using a teaspoon or syringe. It should never be added to a bottle
of milk or formula, as this reduces the bioavailability of thyroxin significantly. The
dosage shouldbe repeated if the baby vomits or regurgitates immediately afterwards.


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Pediatric Conditions
401
URINARY TRACT INFECTION (UTI)
Salient features
Pharmacological treatment
 Patients less than 3 months of age, systemically toxic with high fever, loin pain and
vomiting, and with underlying structural abnormality of urinary tract, are better treated as
inpatients and with parenteral antibiotics. All other patients can be treated as outpatients
with oral antibiotics.
 The initial antibiotic choice should be guidedby local culture and sensitivity report
return. The duration of therapy is 10-14 days for infants and children with complicated
UTI, and 7-10 days for uncomplicated UTI.  Adolescents with cystitis may be treated
with shorter duration antibiotics. Hydration must be maintained with oral or IV fluids as
required.


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with shorter duration antibiotics. Hydration must be maintained with oral or IV fluids as
required.
 Analgesics and antipyretics are used as per necessity.
 Patients with obstructive uropathies may need urgent drainage without which resolution
of UTI may be difficult.
 Maintain adequate hydration and encourage liberal fluid intake to alleviate dysuria. The
antibiotics suggested for the treatment of UTI is as follows:
Table 12. Antibiotics suggested for the treatment of UTI in children
Medication Dose, mg/kg/day
Parenteral
Cefriaxone 75-100, in 1-2 divided doses IV
Cefotaxime 100-150, in 2-3 divided doses IV
Amikacin 10-15, single dose IV or IM
Gentamicin 5-6, single doses IV or IM
Comaxiclav 30-35 of amoxicillin, in 2 divided doses IV
Oral


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Amikacin 10-15, single dose IV or IM
Gentamicin 5-6, single doses IV or IM
Comaxiclav 30-35 of amoxicillin, in 2 divided doses IV
Oral
 It is a common bacterial infection in infants and children. It can be a presenting feature
of underlying structural or functional abnormality of the urinary tract or associated with
renal parenchymal damage, hypertension, and chronic kidney disease. All patients with
recurrent UTI are more at risk and should be investigated and managed thoroughly.
- Ask about bowel bladder habits, checking BP and examining the genitals for
phimosis/balanitis/labial adhesion and spine.High risk factors for underlyingstructural
abnormality, bladder voiding dysfunction and/or chronic kidney disease is: UTI in


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abnormality, bladder voiding dysfunction and/or chronic kidney disease is: UTI in
infant, severe symptoms (fever, loin pain, vomiting, poor response to initial
management) or septicaemia
- Recurrent UTI- Indication of bladder anomaly: severe constipation, urinary dribbling,
poor urinary stream, straining, palpable bladder,renal disease: stunting, raised
creatinine, hypertension, flank mass


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Pediatric Conditions
402
Cefixime 8-10 in 2 divided doses
Amoxicillin 30-50 of amoxicillin, in 3 divided doses
Ciprofloxacin* 10-20, in 2 divided doses
Ofloxacin* 15-20, in 2 divided doses
Cephalexin 50-70, in 2-3 divided doses
* Fluoroquinolones should be avoided as first line medication; their use should be guided by
results of culture and sensitivity.
Monitoring and follow-up of high risk patients
 An abdominal USG and repeat urine culture are necessary in patients who fail to show
clinical response (reduction of fever and toxicity) within 48 hours of initial treatment.
 Ch ild with more than one episode should be worked up for cause of recurrent UTI. Each
episode is treated as mentioned above but child should be investigated in detail with


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episode is treated as mentioned above but child should be investigated in detail with
ultrasound,Micturating Cystourethrogram(MCU) and DMSA scan.
 High risk patients are likely to have underlying abnormalities. Such patients must be
identified early by careful history and examination and investigated. Many of these
patients have recurrent UTI. Underlying vesico-ureteric reflux and bladder-bowel
elimination disorders are themost common etiologies, and specific management
depending on cause has to be initiated.
Antibiotic prophylaxis
Antibiotic prophylaxis has been recommended in the following situations:
 UTI below 1-yr age, while awaiting imaging studies
 Vesico urethral reflux
 Frequent febrile UTI even if the urinary tract is normal.


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 UTI below 1-yr age, while awaiting imaging studies
 Vesico urethral reflux
 Frequent febrile UTI even if the urinary tract is normal.
Antibiotic prophylaxis is not advised in patients with urinary tract obstruction, urolithiasis
and neurogenic bladder, and inpatients on clean intermittent catheterization.
Antibiotics for prophylaxis of urinary tract infections in children
Drug Dose (mg/kg/day) Remarks
Cotrimoxazole
Nitrofurantoin
Cephalexin
1-2 (trimethoprim)
1-2
10
Avoid in infants <3 months age and G -6PD
deficiency
Gastrointestinal upset; avoid in infants <3 months
age, G-6 PD deficiency and renal insufficiency
Drug of choice in first 3-6 months of life
Long -term follow-up
Patients with recurrent UTI, renal scars, or risk factors mentioned above need long-term


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Long -term follow-up
Patients with recurrent UTI, renal scars, or risk factors mentioned above need long-term
monitoring. Patients are advised to have plenty of oralfluids, void regularly, avoid
constipation and maintain perianal hygiene. They should check a clean midstream urine after
local cleansing if any recurrence of fever/any urinary or other symptoms suggestive of UTI.


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Pediatric Conditions
403
POSTSTREPTOCOCCAL ACUTE GLOMERULONEPHRIT IS (AGN)
Salient features
Treatment
 Monitoring of fluid intake, output, blood pressure, urea, creatinine and electrolytes
required on regular basis. Complete blood count,Anti Streptolysin O Titre (ASOT), C3,
renal ultrasound should be performed at presentation.
 Fluid restriction to urine output and insensible losses.
 Inj.Procaine penicillin 4 lac units once daily if evidence of sore throat or skin infection.
 Potassium restriction
 Treatment of complications such as hyperkalemia, hypertension and fluid overload. If
conservative management of these complications is not sufficient for control, early
dialysis should be initiated.
 Treatment of acute hyperkalemia
1 Restrict K intake


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dialysis should be initiated.
 Treatment of acute hyperkalemia
1 Restrict K intake
2 Transient reversal of cardiotoxicity with calcium gluconate(10%)1ml/kg in distilled
water, slow IV infusion
3 Temporary reduction of potassium in extracellular fluid with:
Nebulised salbutamol
Sodium Bicarbonate : 1-2 mmol/kg
Glucose (0.5g/kg) + insulin (0.1U/kg) infusion
4 Removal of potassium from the body by:
Frusemide (1-2 mg/kg)
Potassium exchange resins(1g/kg/day)
Dialysis
Patient education
Parents should be explained the natural course. More than 95% recover within 2– 4 weeks.
Only a few patients may end up with chronic renal insufficiency.
 Commonest type of post infectious acute glomerulonephritis
 Immunological disease occurring after groupA beta hemolytic streptococcal throat or


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 Commonest type of post infectious acute glomerulonephritis
 Immunological disease occurring after groupA beta hemolytic streptococcal throat or
skin infection resulting in diffuse proliferative glomerulonephritis.
 Sudden onset of hematuria, oliguria, edema and hypertension.
 Children between 5-10 years are commonly affected.
 Investigations reveal raised urea,creatinine, positive tests for streptococcal infection,
low C3 level.Renal biopsycan be donein severe and prolonged case of AGN.
 Complications include hyperkalemia, acute renal failure, hypertensive encephalopathy
and severe fluid overload causing pulmonary edema.


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Pediatric Conditions
404
NEPHROTIC SYNDRO ME
Nephrotic syndrome is an important chronic disorder in children. It can be primary
(idiopathic) or secondary (SLE, Henoch Schonlein purpura, amyloidosis etc). About 90%
children with idiopathic nephrotic syndrome have 'minimal lesion' on renal histologyand
respond promptly to corticosteroids. Approximately three fourth patients have one or more
relapses. Steroid toxicity and frequent serious infection complicate such cases.
Salient features
Pharmacological treatment
Definitionsuseful for guiding treatment are as follows:
- Remission:Urine albumin nil or trace (or proteinuria <4 mg/m2/h) for 3 consecutive days.
- Relapse: Urine albumin 3+ or 4+ (or proteinuria >40 mg/m2/h) for 3 consecutive days
having been in remission previously.


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- Relapse: Urine albumin 3+ or 4+ (or proteinuria >40 mg/m2/h) for 3 consecutive days
having been in remission previously.
- Frequent relapses: Two or more relapses in six months of initial response, or more than
three relapses in any twelve months.
- Steroid dependence: Two consecutive relapses when on alternate day steroids or within
14 days of its discontinuation.
- Steroid resistance: Absence of remission despite therapy with 4 weeks of daily
prednisolone in a dose of 2 mg/kg per day
 Steroid Sensitive Nephrotic Syndrome (SSNS)
- The first episode:Prednisolone 2 mg/kg/day (or 60 mg/m2/day) after food for 6 weeks,
followed by 1.5 mg/kg/alternate day (or 40 mg/m2/alternate day) for 6 weeks.
- Infrequent relapses:Prednisolone 2 mg/kg/day until remission followed by 1.5


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- Infrequent relapses:Prednisolone 2 mg/kg/day until remission followed by 1.5
mg/kg/day for 4 weeks.
- Frequent relapses and steroid dependant (SDNS):the following options are used
successively.
- Prednisolone for achievement of remission followed by maintenance of a low dose (<than
0.5 mg/kg) on alternate day basis for 12-18 months.
- Levamisole 2.5 mg/kg/alternate day for 6 to 24 months. Monitoring of CBC is required 1-
2 monthly.
- Cyclophosphamide (CP) 2-3 mg/kg/day for 2-3 months to achieve a cumulative dose of
168 mg/kg. CBC monitoring is required 1-2 weekly.
- Mycophenolate mofetil (MMF) 20-30 mg/kg/day
- Tacrolimus (TAC) 0/1-0.2 mg/kg/day
 Heavy proteinuria, hypoalbuminemia (S, Albumin <2.5 g/dl), hyperlipidemia (S.


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- Tacrolimus (TAC) 0/1-0.2 mg/kg/day
 Heavy proteinuria, hypoalbuminemia (S, Albumin <2.5 g/dl), hyperlipidemia (S.
cholesterol >200 mg/dl) and oedema. Dipstick or heat coagulation of urine shows
3+/4+ proteinuria.
 Investigations which help in diagnosis and management are urine analysis, blood
counts, S. cholesterol, S. proteins, blood urea, S.creatinine, urine culture, X-ray chest,
Mantoux, HBsAg.


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Pediatric Conditions
405
- Cyclosporine A (CSA) 3-5 mg/kg day
- Rituximab (RTX) is a relatively new and potent therapy which is used only rarely for
extremely difficult cases that does not respond to other options.
- Note: A renal biopsy is advised before starting TAC or CSA. Immuno-suppressive
therapy requires supervision by paediatric nephrologist and monitoringof hemograms
(for all), liver function (MMF and TAC) and glucose and magnesium levels (TAC), renal
function (TAC and CSA) and drug levels (MMF, TAC, CSA).
Figure 2. Treatment of steroid sensitive nephritic syndrome without hypertension,
hematuria and azotemia
Supportive Treatment
 Detect and treat infections rapidly.
 Mobilize the patient early


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hematuria and azotemia
Supportive Treatment
 Detect and treat infections rapidly.
 Mobilize the patient early
 Antacids, H2 receptor blockers or proton pump inhibitors are often prescribed along with
steroids but they are no definite evidence to support this in patients who do not have any
symptoms of gastritis.
 Calcium and vitamin D supplements may be used to reduce osteopenic effects of steroids,
however definitive evidence and guidelines are not yet available.
 Diet: Avoid excessive salt intake in edematous patient. A balanced diet with less than
30% fats and at least 2 gm/kg/day protein is advised.
 Edema should be treated cautiously with diuretics while closely monitoring hypovolemia
and renal function.


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 Edema should be treated cautiously with diuretics while closely monitoring hypovolemia
and renal function.
 Hypovolemia should be detected rapidly and treated by fluids and colloids.
 Patients who are chronically nephritic may have hyperlipidemia which is managed by diet
and if persistent, with statins.
 Hypertension should be controlled and BP maintained below 90th percentile of age.


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Pediatric Conditions
406
 Complete immunization when the patient is in remission. Vaccinate for varicella and
pneumococcus. Avoid live vaccines during immunosuppressive therapy and for 3 months
after cessation.
 Stress dose of hydrocortisone (2-4 mg/kg/day) should be used in patients who have
received high dose steroids for 2 weeks or more in the past year, when they present with
serious infections or other critical illnesses, or if undergoing major surgery.
Follow up and monitoring
 Monitor urinary protein at home and attend if it is 2+ or more
 Monitor blood pressure, growth and eye examination yearly
 Urine output and weight record
Parent education
 Assurance that despite a relapsing course, progression to end stage renal disease is rare


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 Urine output and weight record
Parent education
 Assurance that despite a relapsing course, progression to end stage renal disease is rare
 Urine examination by sulfosalicylic acid (SSA), dipstick or boiling should be taught.
 Maintain adiary showing proteinuria and medication received.
 Ensure normal activity.
 Protection against infection
FEBRILE SEIZURES
Febrile seizures are brief (2-5 min), generalized tonic-clonic and self limited seizures
followed by a brief post-ictal period of drowsiness, in a febrile child of 6 months to 5 years of
age, without any underlying neurological disease. They occur rarely before 6 months and
after 5 year of age. The peak age of onset is approximately 14-18 months of age, found in 3-


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after 5 year of age. The peak age of onset is approximately 14-18 months of age, found in 3-
4% of young children.There is a strong family history of febrile convulsions in siblings and
parents, suggesting a genetic predisposition. Except for the cases at high risk, simple febrile
seizures rarely develop into epilepsy.
Salient features
 Febrile seizures usually occur when the temperature is rising rapidly, to generally 39°C
(102°F) or more of core temperature.
- They are of two types: Typical (Simple) febrile seizure occurs on day 1 of fever, does
not last  for more than 10 minutes; Atypical or complex febrile seizure may persist for
more than 15 minutes; itcould be focal in nature; more than one episode of seizure in


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more than 15 minutes; itcould be focal in nature; more than one episode of seizure in
24 hours;associated with abnormal neurological findings or deficits. An organic cause
such as an infectious or toxic process should be considered and investigated.
 Examination of CSF is to rule out possibility of meningitis in cases with first episode of
febrile seizures.
 EEG is not required in a simple case of febrile seizures.However, in cases with atypical
febrile seizure or in a child with high risk for developing epilepsy, it may be helpful.


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Pediatric Conditions
407
Non -pharmacological treatment
Clear the airway, semi-prone lateral position and oxygen therapy.
Pharmacological treatment
Most febrile seizures are brief and would be over by the time a childis brought to the doctor
or health facility.Careful search for the cause of fever and treat fever.
 In cases presenting with seizures, the mainstay of management is prompt administration
of anticonvulsants.
 The best drug is diazepam in a dose of 0.3 mg/kg by slow intravenous or rectal route. It
can be repeated if seizures do not subside (per rectal dose may be given up to 0.5
mg/kg/dose). Lorazepam can be used as an alternative.
Intermittent prophylaxis (during febrile illness)
Tab/Syr. diazepam 0.3 mg/kg/dose every 8 hours (1 mg/kg/day) for 2-3 days of febrile


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Intermittent prophylaxis (during febrile illness)
Tab/Syr. diazepam 0.3 mg/kg/dose every 8 hours (1 mg/kg/day) for 2-3 days of febrile
illness, started on theday of onset of fever. Dose can be adjusted if over sedation or ataxia
noted.
Continuous prophylaxis
Phenytoin and carbamazepine are ineffective for prophylaxisand phenobarbitone has serious
effects on cognitive function. Sodium valproate is effective butpotential risk does not justify
its use.
Patient education( parents/care taker)
 Assure the benign nature of the disease with  no neurological deficit or mental retardation
as a result of simple febrile seizure.  Teach to control of fever and to give diazepam per
rectally at home.
 Routine immunization as per schedule should be followed. After DPT vaccination, oral


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rectally at home.
 Routine immunization as per schedule should be followed. After DPT vaccination, oral
paracetamol 15 mg/kg/dose every 6 h for 2 or 3 days and similarly, after measles
vaccination, oral paracetamol in the same dose started on the 4th day from the day of
vaccination and given for 3 to 4 days to avoid precipitation of febrile seizures.
ACUTE PYOGENIC MENINGITIS (CSF or clinically proven)
Acute meningitis is an acute inflammatory process involving brain tissue, due to infectious
causes. The common aetiological agents are viruses and bacteria. Children of any age may be
affected.
Salient features
 Fever, headache, vomiting, irritability, altered state ofconsciousness, signs of
meningeal irritation and seizures. CSF examination differentiates the viral from
bacterial causes.


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Pediatric Conditions
408
Diagnosis
Table 13. CSF findings in meningitis
Pressure
(mmH 20) Leucocytosis (mm3) Protein
(mg/dl) Glucose (mg/dl)
Normal 50-80 <5,>75% Lymphos 20-45 >50 or 75%
serum glucose
Acute bacterial
meningitis
Usually elevated
(100-300)
100-10,000 PMN's*
predominate 100-500 Decreased (<40)
Acute viral
meningo-
encephalitis
Normal or elevated
Rarely >1000 PMN's
early but Lymphos
predominate in the most
of the course
50-200 Normal rarely-
decreased
Tubercular
meningo-
encephilitis
Usually elevated
100-500 PMN's early but
later lymphocytes
predominate
100-3000 <50
Pharmacological treatment
Supportive treatment is the mainstay of therapy and isstarted immediately.
 Maintain airway, breathing and circulation.


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Pharmacological treatment
Supportive treatment is the mainstay of therapy and isstarted immediately.
 Maintain airway, breathing and circulation.
 Control seizures with IV injection of diazepam 0.2 to 0.4 mg/kg stat followed by inj.
phenytoin 10– 20 mg/kg stat followed by 5 mg/kg/day in divided doses.
 Increased intracranial tension istreated by proper positioning of the patient with head
elevated at 15– 30º position, fluid restriction to 2/3rd of maintenance, 20% mannitol 5
ml/kg over 10– 15 mins. followed by 3 ml/kg every 6 hours for 48 hours and then SOS
Or glycerine 1 ml/kg/day through feeding tube may be added if increased intracranial
tension persists.
 Fever is controlled as given in section of fever (do not give aspirin).


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tension persists.
 Fever is controlled as given in section of fever (do not give aspirin).
 The intravenous fluid is two thirds of the maintenance requirement initially.
 Feeding: Initially thepatient is kept nil orally for the first 24– 48 hours. Later on the
feeding is guided by the level of sensorium. Tube feeding is helpful for feedings as well
as giving medicines.
Specific Management
 Untila bacterial cause is excluded, parenteral antibiotic therapy should be administered.
The choice of antibiotics depends upon age of the patient and prevalence of organism in
the area.
Age 0-3 months
 Inj.cefotaxime 200 mg/kg/day IV in 4 divided doses for 14 days.
 Inj.ampicillin 300 mg/kg/day IV in 4 divided doses for 14 days.


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Pediatric Conditions
409
Age 3 months-12 years
 Inj. ceftriaxone 100 mg/kg/day IV in 2 divided doses for 10 days
Or Inj.cefotaxime 200 mg/kg/day IV in 3 divided doses for 10 days  Or Inj ampicillin
300 mg/kg/day IV in 4 divided doses for 10 days
 Inj.chloramphenicol 100 mg/kg/day in 4 divided doses for 10 days
 IfMeningococciis suspected/isolated Inj.penicillin G 300,000-400,000 IU/kg/ day in 4
divided doses for 7-10 days.
Advice at discharge
 Regular follow up for neurological assessment including deafness is advised.
 Anticonvulsant therapy to be continued if seizures are recurrent during course of
meningitis. Children with sequelae would require assessment of handicap and
multidisciplinary management. Physiotherapy may be taught during hospital stay itself.


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multidisciplinary management. Physiotherapy may be taught during hospital stay itself.
TUBERCULAR MENINGITIS (TBM)
It is the inflammation of the meninges due to lymphohematogenous spread of the primary
infection of tuberculosis.
Salient Features
Diagnosis
 CSF on lumbar puncture which shows lymphocytic leucocytosis with elevated proteins
and a low sugar level. Demonstration of AFB in the CSF confirms the diagnosis but the
yield is very poor.
Non -pharmacological treatment
 Nutrition rehabilitation should be done as given in section on protein energy malnutrition.
 Skin care and prevention of bedsores. Care of bowel and bladder.
 Physiotherapy and occupational therapy should be instituted early to prevent deformities
and contractures.
Pharmacological treatment


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 Physiotherapy and occupational therapy should be instituted early to prevent deformities
and contractures.
Pharmacological treatment
 Appropriate fluid therapy to correct dehydration due to frequent vomiting and decreased
oral intake.
 Clinical progression is in three stages:1st stage– lasts for 1– 2 weeks, characterized
by non specific symptoms, fever, headache,irritability, drowsiness, malaise. 2nd stage
– begins more abruptlywith common featuresof lethargy, neck rigidity, seizures,
positive Kernig or Brudzinski’s sign, cranial nerve palsies and other focal
neurological signs. 3rd stage– marked by coma, hemiplagia or paraplegia, decerebrate
posturing, deterioration of vital signs and eventually death.


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neurological signs. 3rd stage– marked by coma, hemiplagia or paraplegia, decerebrate
posturing, deterioration of vital signs and eventually death.
 Complications include motor deficits, cranial nerve deficits, mental retardation,
seizures, hydrocephalus, blindness etc.


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Pediatric Conditions
410
 Inj. dexamethasone: 0.15 mg/kg IV 6 hourly for 2 weeks followed by Tab. prednisolone
1.5 mg/kg/day orally through feeding tube for 4 weeks. This should be tapered over
another 2 weeks. A total of 6-8 weeks therapy with steroid is recommended.
 Mannitol (20% solution) 1.5 to 2 g/kg or 8-10 ml/kg over 30-60 minutes. Repeated every
6-8 hours for 7 days. Lower doses (0.25 g/kg/dose) can also be tried. Or Glycerol 1
ml/kg/dose every 6-8 hours, diluted in orange juice or water, given through feeding tube.
Or Tab. acetazolamide 50 mg/kg/day, in 3 divided doses for 2-3 weeks.
 Presence of seizures necessitates treatment with phenytoin or carbamazepine in
appropriate doses.
 Specific antitubercular therapy-as given in management of tuberculosis


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appropriate doses.
 Specific antitubercular therapy-as given in management of tuberculosis
 Surgical Treatment-Ventriculoperitoneal Shunt (VP Shunt): TBM shows some degree of
hydrocephalus by 4 weeks. Obstructive hydrocephalus should be shunted immediately.
Non obstructive hydrocephalus with increased intracranial pressure as shownby
ventricular tap or CT scan will also be benefited by VP shunt. An early shunt is
preferable.
Follow up
 Patient should be kept under follow up after discharge from the hospital and assessed for
neurological deficit and features of increased intracranialpressure (ICP). One of the
common causes of increased ICP is untreated hydrocephalus or blocked shunt.
 Check compliance to drugs and ensure that occupational therapy/physiotherapy is being
continued.


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 Check compliance to drugs and ensure that occupational therapy/physiotherapy is being
continued.
 Assess physical, mental, visual and auditory handicap and consider rehabilitation from
specialists.
Patient education
 Seriousness of disease must be explained. Contact survey must be done and any other
members of the family found to have active TB should be counselled to attend TB clinic
for therapy.
 Need forcompliance must be explained.
STATUS EPILEPTICUS
It is a single epileptic seizure of >30 minute in duration or a series of epileptic seizures during
which consciousness is not regained between ictal events in a >30 min period (International
League against Epilepsy).
Pharmacological treatment
 Inj.Lorazepam 0.1 m g/kg (max 4 mg) @ 2 mg/m in Or Inj. Midazolam 0.15-0.2mg /kg


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League against Epilepsy).
Pharmacological treatment
 Inj.Lorazepam 0.1 m g/kg (max 4 mg) @ 2 mg/m in Or Inj. Midazolam 0.15-0.2mg /kg
iv/im (max 5 mg),If ivaccessis notavailable,buccalm idazolam 0.3 mg/kg (max 5mg)
or perrectal diazepam 0.5mg /kg (max 10 mg)
 Establishairway,breathing,circulation. Monitor cardiorespiratory status / oxygenation
 Investigations:


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Pediatric Conditions
411
- Glucose,sodium, potassium,C alcium, mag nesium, C R P,A ED level,LFT ,RFT ,
After 10 minutes,
 Inj. phenytoin 20 mg/kg in NS(max. 1000mg)@1 mg /kg/m inOr Inj. fosphenytoin PE 20
mg/kg in NS@ 3 mg/kg/m in
If no response,
 RepeatInj. phenytoin 20 mg/kg in NS(max. 1000mg)@1 mg /kg/m in
(Seizersoccurring even after 10 mins.of phenytoin/ fosphenytoinadministration refers to
refractory status)
At 25-30 mins.
 Inj.valproate 20 mg/kgiv @ 6 mg/kg/m in orInj.phenobarbitone 20m g/kgiv @ 1.5
mg/kg/m in
If no response after 35-45-mins.,
 Inj.phenobarbitone 10 mg/kg iv
HYPOVOLEMIC SHOCK
Hypovolemic shock, the most common cause in children is most frequently caused by
diarrhea, vomiting or hemorrhage. The etiology of hypovolemic shock includes blood Loss:


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diarrhea, vomiting or hemorrhage. The etiology of hypovolemic shock includes blood Loss:
hemorrhage, burns, nephrotic  syndrome,  water/electrolyte loss-vomiting, and diarrhea
Pharmacological treatment
 IV or intraosseous access
 Rapid administration of 20 ml/kg of isotonic saline over 5-10 minutes.
 Repeat up to 60-80 ml/kg of isotonic saline if required; not unusual for severely affected
patient to require this volume in first hour.
 Shock refractory to this requires inotropic therapy with dopamine, dobutamine or nor-
epinephrine.
 Inj. dopamine: 3-20 microgram/kg/min IV or Inj. dobutamine: 1-10 microgram/kg/min IV
or  Inj. nor-epinephrine: 0.05-1.5 microgram/kg/min
 In case of heamorrhagic shock stop ongoing blood loss, PCV may be required


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or  Inj. nor-epinephrine: 0.05-1.5 microgram/kg/min
 In case of heamorrhagic shock stop ongoing blood loss, PCV may be required
 In case of nephrotic syndrome IV albumin is required.
 Treat diarrhea and vomiting with appropriate antibiotics, anti-emetics and  H2 receptor
blockers or proton pump inhibitors.
DIPHTHERIA
Diphtheriais caused byCorynebacterium diphtheriae,
Salient features
 Fever of 38°C (100.4°F), chills,fatigue, sore throat, hoarseness, cough, difficulty
swallowing, painful swallowing, difficulty breathing, foul-smelling bloodstained nasal
discharge


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Pediatric Conditions
412
Non -pharmacological treatment
 Hydration and maintain Airway– tracheotomy if hypoxia
Pharmacological treatment
 Inj. diphtheria Antitoxin 20000to 100000 IU after test dose
 Inj. crystalline penicillin 1,00,000-1,50,000 IU/Kg/Day IV in 4 divided doses for 14 days
if patient allergic to penicillin erythromycin 40 mg/kg/day in 4 divided doses for 14 days
Prevention
 DTP as per immunization schedule
SE VERE MALARIA
Salient features
Minor Criteria
Pharmacological treatment
Choice of antimalarial drugs
Supportive therapy
 Preferably manage the patients  in ICU.
 Clinical assessment with special attention to level of consciousness, BP, rate and depth of
respiration and pallor should be made.
Drug Dose Duration


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respiration and pallor should be made.
Drug Dose Duration
Artesunate 2.4mg/kg IV f/b 1.2mg/kg after 12 & 24 hrs & then
daily till orally can be started(4mg/kg/day)
5 – 7 days
Quinine 20mg/kg IV loading of salt f/b 10mg/kg/dose q 8 hrly
till orally can be started
7 days
Primaquine 0.75mg/kg orally 1 day
 CerebralMalaria-failure to localize or respond to noxious stimuli (GCS </=8).
 Convulsion-More than 2 generalized convulsions within 24 hours despite   cooling.
 Severe Normocytic   normochromic anaemia - Hematocrit <15%,or hemoglobin
<5g/dl
 Acidosis– Arterial pH<7.25,plasmaHCO 3 <15mMo1/L, venous lactate > 6mMo1/L
 Renal failure- Urine output<0.5ml/kg/hr with no improvement on rehydration and
S.creat >3mg/dl
 Hypoglycemia- Whole blood glucose <40 mg/dl, Macroscopic hemoglobinuria


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S.creat >3mg/dl
 Hypoglycemia- Whole blood glucose <40 mg/dl, Macroscopic hemoglobinuria
 Minor criteria-Impaired consciousness-Less severe alteration of sensorium should be
considered as correlate of cerebral malaria. Profound weakness unable to sit or walk
with no neurological explanation
 Hyperparasitemia-Parasite count >2,50,000/µl or >5% RBC’s parasitized
 Jaundice-Detected clinically or S.bilirubin >3 mg/dl
 Hyperpyrexia– Rectal temperature > 400


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Pediatric Conditions
413
 A good airway, semilateral position and nasogastric tube insertion in unconscious patients,
ventilatory support for children with Balyntyre score < 11 is necessary.
 Oxygen, IV fluids and ionotropes for management of shock.
 Anti-convulsants. Anti-pyretics.
 Blood products to be given as indicated.
 Fluid input and output, daily weight of the patient to be done.  Temperature and vitals
monitoring.  Frequent change of positions 2 hourly to avoid bed sores.
HYPERTENSIVE ENCEPHALOPATHY
Most commonly associated with renal disease in children, including acute
glomerulonephritis, chronic pyelonephritis and end-stage renal disease. In some cases may be
the initial manifestation of underlying renal disease. Cerebral vasoconstriction which is


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the initial manifestation of underlying renal disease. Cerebral vasoconstriction which is
caused by systemic hypertension leads to focal areas of cerebral edema and hemorrhage.
Salient features
Pharmacological Treatment
Anti-hypertensives
Drug Dosage & route Side-effects
Nifidipine 0.25-0.5 mg/kg per dose (maximum dose 10 mg)
sublingual or oral q 6 hr
Flushing,headache,
tachycardia
Hydralazine 0.1-0.2 mg/kg IM or IV repeat after 4-6 hr. For
maintenance 1.5-3.5 mg/kg/day in 4 divided doses
PO
Flushing,headache,
tachycardia
Reserpine 0.02 mg/kg/doseIM or PO q 12 hr, upto maximum
of 0.07 mg/kg or 1 mg
Drowsiness, nasal
congestion, GI bleeding
Diazoxide 1 mg/kg IV bolus, repeat q 15 min till blood
pressure is controlled or maximum dose of 5 mg/kg
is given
Hyperglycemia
 Anti-convulsants


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Diazoxide 1 mg/kg IV bolus, repeat q 15 min till blood
pressure is controlled or maximum dose of 5 mg/kg
is given
Hyperglycemia
 Anti-convulsants
Drug Dosage & route Side-effects
Phenytoin 20 mg/kg IV slowly @ 25 mg/min
followed by maintenance dose of 5
mg/kg q 12 hr
Watch for hypotension and
arrhythmia
Phenobarbitone 20 mg/kg loading dose IV @
2mg/kg/min followed by maintenance
dose of 5 mg/kg q 12 hr
Watch fo r respiratory
depression
 Acute seizures and coma or may manifest with headache, drowsiness and lethargy,
nausea and vomiting,blurredvision, transient cortical blindness and hemiparesis.


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Pediatric Conditions
414
Diazepam 0.2-0.5 mg/kg IV bolus over 1-2 min Watch for respiratory
depression and hypotension
Lorazepam 0.05-0.1 mg/kg(max upto 4 mg) IV over
1-2 min
Although little but there is risk
of respiratory depression and
hypotension
Mi dazolam 0.2 mg/kg IV bolus. Respiratory depression.
 Treat underlying condition.
ACUTE SEVERE ASTHMA
An acute exacerbation of asthma that does not respond to conventional therapy is called
status asthmatics.
Salient features
Symptoms/signs Mild Mode rate Severe
Respiratory rate Normal Increased Increased
Alertness Normal Normal Restless/drowsy
Dyspnoea Absent or mild moderate Severe
Pulsus paradoxus <10mmHg 10 – 20mm Hg 20 – 40mmHg
Accessory muscle
use
No or mild
intercostals
retractions
Moderate intercostals
interactions with


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Pulsus paradoxus <10mmHg 10 – 20mm Hg 20 – 40mmHg
Accessory muscle
use
No or mild
intercostals
retractions
Moderate intercostals
interactions with
tracheosternal
retractions
Severe intercostal
interactions with
tracheosternal
retractions with nasal
flaring
Colour Pink Pale G rey or cyanotic
Auscultation End expiratory
wheeze only
Wheeze during
expiration&
inspiration
Breath sounds
inaudible
Oxygen saturation >95% 90 – 95% <90%
Paco2 <35mm Hg 35 – 40 mmHg >40 mmHg
PEFR 70 – 90% of
predicted orbest
50 – 70% of predicted
or personalbest
<50% of predicted or
personal best
 Assessment of severity of acute attack of asthma
Life threatening asthmaSilent chest, Cyanosis,  Poor respiratory effort, Hypotension
Exhaustion, Confusion,  Spo2 <92% , PEFR <33% best/predicted


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Life threatening asthmaSilent chest, Cyanosis,  Poor respiratory effort, Hypotension
Exhaustion, Confusion,  Spo2 <92% , PEFR <33% best/predicted
Acute severe asthma Can’t complete sentences in one breath or breathless to talk or feed
Spo2 <92%,  PEFR 33– 35% best or predicted
Pulse >140/min in 2 to 5 years
>125/min in >5 years
Respiration >40breaths/min in 2 to 5 years, 30/min in 5 to 7 years


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Pediatric Conditions
415
Moderate asthma
exacerbation
Able to talk in sentences
Spo2 >/=92% , PEFR 50% best or predicted
Pulse </=140/min in 2 to 5 years
</=125/min in >5 years
Respiration </=40breaths/min in 2 to 5 years
</=30/min in 5 to 7 years
Pharmacological treatment
Initialassessment-
Imp endingrespiratory failure, Moderate to severeattack-
 Oxygen
 N ebulizersalbutamol + ipratropium
 Inj. terbutaline /adrenaline SC
 IV corticosteroids
 Transfer to ICU-Good response
Life threatening attack
 Same as above+ Reassessafter 1 hr.
If poor/ partial response,
 Co rrectacidosis
 Trial of Mg So4/ terbutaline
If no response after 2-4 hrs.
 Continue above treatment and add Inj.amoniphylline infusion


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416
Chapter 19
DENTAL CONDITIONS
TOOTH AVULSION
One of the commonest sequelae of facial trauma is tooth avulsion, exfoliation or articulation.
Salient features
Treatment
 Immediately refer to a dentist.Best result is observed if tooth is reimplanted within 5-20
minutes.
 Fixation of implanted tooth with periodontal wiring, arch bar wiring or composite resin;
fixation period 6 to 8 weeks; root canal treatment done after reimplantation only (to avoid
desiccation of periodontal ligament).
Interim storage
 Best method is to place back the tooth in the socket immediately. Other storage media are
saliva, milk (placed in ice since this minimizes the adverse effects on the periodontal
ligament) and saline.
Pharmacological treatment


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saliva, milk (placed in ice since this minimizes the adverse effects on the periodontal
ligament) and saline.
Pharmacological treatment
 Cap. amoxycillin 250-500 mg 3 times a day for 5 days Or Tab. ciprofloxacin 250-500 mg
twice a day for 5 days.
 Tab. diclofenac Potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times for 3-5 days.
TOOTHACHE
Direct causes are dentalcaries, periodontal pocket, abrasion, attrition & erosion,peridontitis,
third molar eruption (Impacted Tooth). The indirect causes of toothache are maxillary
sinusitis (recent bout of common cold) & trigeminal neuralgia.
Pharmacologicaltreatment
 Cap. amoxycillin 250-500 mg 3 times a day for 5 days. Or Tab. ciprofloxacin 250-500
mg 2 times a day for 5 days.


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Pharmacologicaltreatment
 Cap. amoxycillin 250-500 mg 3 times a day for 5 days. Or Tab. ciprofloxacin 250-500
mg 2 times a day for 5 days.
 Tab. diclofenac potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times for 3-5 days.
Surgicaltreatment
 Excavation of caries and sedative dressing with clove oil. Removal of plaque & calculus
by scaling & local medicaments.Removal of irritant like high filling and high spot on
crown or bridge.Anaesthetize the tooth and extirpate the pulp (if pulp is exposed).
 History of fall, interpersonal violence, sports injury, assault or accident.
 Children are morecommon.
 Central incisors and developing teeth are more frequently avulsed.
 Patient presents extreme pain with a bleeding socket, clot in the socket and a raw


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 Patient presents extreme pain with a bleeding socket, clot in the socket and a raw
wound with or without Lip & Labial mucosa injury.


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Dental Conditions
417
 Removal of Impacted third molar.
 Treatment should be with radiographs to ruleout cause & radiograph after 6 weeks to
assess bone loss and root resorption.
Patient education
 Maintenance of oral hygiene.
 Importance of tooth preservation should be explained.
 Pit and fissure sealing in pediatric patient.
 Not to bite anything hard from anterior teeth during fixation period.
TOOTH FRACTURE/ MANDIBLE OR MAXILLARY BONE FRACTURE
Salient features
Treatment
 Perform primary treatment for bleeding & pain
 Primary sutures for soft tissue trauma
 Radiographs for fracture suspected sites
 Refer to oral maxilla facial surgeon for bone fractures
DENTAL CARIES
This is a multifactorial infectious disease of hard tissues of teeth characterized by


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DENTAL CARIES
This is a multifactorial infectious disease of hard tissues of teeth characterized by
demineralization of inorganic and destruction of organic part of the tooth. (Enamel & Dentin)
Salient features
Treatment
 Examine for stage of caries and treat accordingly.
 Careful assessment of oral cavity for presence of any white/ brown or black spot.
Non -pharmacologicaltreatment
 In non-cavitated lesion and low risk patient with good oral hygiene practices, no
treatment is given.
 In cavitated lesion, restoration is done.
Pharmacologicaltreatment
 Patients with caries is likely to progress (in high risk patient) pit and fissure sealant.
 Topical 2% sodium fluoride.
 Pain, mobility of fractured segment of tooth or bone
 Step deformity,Painful or restricted TMJ movement


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 Topical 2% sodium fluoride.
 Pain, mobility of fractured segment of tooth or bone
 Step deformity,Painful or restricted TMJ movement
 Bleeding from traumatic site
 Usually asymptomatic in early stages.
 Patient presents with tooth sensitivity and tooth ache only on cold & sweet intakes
which may disappear on removal of stimuli.


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Dental Conditions
418
 Mouth wash with 0.2% chlorhexidine twice a day.
 Advisefluorinated toothpaste or fluorinated mouthwashes.
Assessment of response to therapy
 For caries active patient-follow up visit every 3 months and to check the progression of
white / brown or black spot on the teeth.
 For normal patients-follow up every6 months to 1 year to check the development of the
white spot cavitation.
Patient education/prevention
 For caries active/high risk patient preferably.
 Diet control and avoidance of sugar containing food.
 Frequent ingestion of food containing sucrose shouldbe substituted by sugar free foods.
 Oral hygiene: (a) brushing of teeth twice a day (b) flossing (c) thorough rinsing after
every meal.


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 Oral hygiene: (a) brushing of teeth twice a day (b) flossing (c) thorough rinsing after
every meal.
 Fluoride application using Topical 2% sodium fluoride (by dentist) 4 applications at
weekly intervals at the age of 3,7, 11 and 13 years.
 0.05% sodium fluoride daily rinse (should not be swallowed).
 0.2% sodium fluoride supervised weekly rinse in school (age of children >7 years) only if
these children have been identified as caries active patients.
References
1. Sturdevant CM. Roberson TM, Heymann HO, Sturdevant JR. In: The Art andScience of Operative Dentistry,
3rd Edition, Mosby 1995, pp 100-20.
2. Mitchell DA, Mitchel L. In: Oxford Handbook of Clinical Dentistry, 2nd Edition, reprint 1996, pp 28.
DENTAL ABSCESS


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2. Mitchell DA, Mitchel L. In: Oxford Handbook of Clinical Dentistry, 2nd Edition, reprint 1996, pp 28.
DENTAL ABSCESS
Patient presents with pain and swelling. The most common types of dental abscesses are
periapical abscess and lateral periodontal abscess.
I. PERIAPICAL ABSCESS
Salient features
Immediate treatment
 To give antibiotics as given below and refer to a dentist.
Ph armacologicaltreatment
 Cap. amoxycillin 250-500 mg 3 times a day for 5 days. Or Tab. ciprofloxacin 250-500
mg two times a day for 5 days.
 Tab. diclofenac potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times a day for 3-5
days.
 Presence of caries or trauma.Severe throbbing pain, disturbed sleep
 Tooth is tender to touch & extruded from socket.Tooth may be mobile and associated


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 Tooth is tender to touch & extruded from socket.Tooth may be mobile and associated
with localized or diffuse swelling.


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Dental Conditions
419
Surgicaltreatment
 Drainage of pus by entering the pulp chamber (pulpectomy) & relieve occlusion.
 If fluctuant swelling of soft tissue is present drain by incision.
 Extraction or root canal treatment should be done when acute symptoms subside.
 Spread of infection should be closelyobserved to prevent complications like Ludwig's
angina or osteomyelitis.
Patient education
 Maintenance of oral hygiene (see details in section on oral hygiene).
 Control of diabetes mellitus, if present.
 No hot fomentation over the skin.
II.LATERAL PERIDONTA L ABSCESS
Salient features
Pharmacologicaltreatment
 Cap. amoxycillin 250-500 mg 3 times a day for 5 days.
 Tab. metronidazole 400 mg 3 times a day for 5 days.


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Pharmacologicaltreatment
 Cap. amoxycillin 250-500 mg 3 times a day for 5 days.
 Tab. metronidazole 400 mg 3 times a day for 5 days.
 Tab. diclofenac potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times/dayfor 3-5 days.
Surgicaltreatment
 D ebridement of pocket and drainage of pus and irrigation with chlorhexidine. Spread of
infection to be closely observed to prevent complications like Ludwig's angina.
Patient education
 Maintenance of oral hygiene.No hot fomentation over the skin.Control of diabetes
mellitus if present.
ADULT TYPE PERIODONTITIS
Most common dental disease of the gums & periodontium.
Salient features
 Same as in acute periapical abscess,often associated with bad taste.
 Tooth is usually mobile and tender on percussion, associatedwithlocalized or diffuse


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 Tooth is usually mobile and tender on percussion, associatedwithlocalized or diffuse
swelling of the adjacent periodontium.
 Vitality test usually positiveif no associated pulpal problem.
 Radiograph shows vertical or horizontal bone loss in relation to the tooth.
 Swollen gums, bleeding from gums either spontaneously or while brushing. Pain on
eating something hard, difficulty in chewing food, dull pain in the gums, pus
discharge from gum on pressing, loosening of teeth, recession of gums.
 There is slowly progressive destruction of periodontitum, loss of periodontal
attachment and presence of periodontal pocket.
 Bad breath (Halitosis),sensitivity to hot & Cold intakes


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Dental Conditions
420
Non -pharmacologicaltreatment
 Refer to a dentist for oral prophylaxis in form of thorough scaling androot planning.
 Advise brushing twice daily once after breakfast and once after dinner with super soft
tooth brush for at least 3 minutes.
Pharmacologicaltreatment
Local therapy
 Advise antiplaque toothpast containing antibiotics.
 Gel metronidazole to be massaged on the gums twice daily.
 Rinsing with 0.2% chlorhexidine mouthwash twice daily which is effective after scaling.
Systemic therapy
 In adults, Cap. tetracycline 250 mg 4times a day for 5-7 days.
 In very deep pockets: Combination of drugs i.e., Tab. ciprofloxacin 500 mg twice daily &
Tab. tinidazole 300 mg twice daily for 5-7 days.


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 In very deep pockets: Combination of drugs i.e., Tab. ciprofloxacin 500 mg twice daily &
Tab. tinidazole 300 mg twice daily for 5-7 days.
 Recheck the depth of periodontal pockets, if it persists, refer to dentist for further
management.
References
1. Ramford and Ash. Peridontology and Periodontitis. In: Moderntherapy and practice. 1st Indian Edition,
AITBS Publishers 1996, pp 163.
2. Mitchell D A, Mitcchell L. In: Oxford Handbook of Clinical Dentistry, 2nd Edition reprint. 1996, pp. 212.
JUVENILE PERIODONTITIS
It is characterized by rapid destruction of periodontal tissues.
Salient features
Pharmacologicaltreatment
 Cap. tetracycline 250 mg 4 times a day for 14 days.
Surgicaltreatment
 Extraction of badly involved teeth. Refer the patient to periodontist for further


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Surgicaltreatment
 Extraction of badly involved teeth. Refer the patient to periodontist for further
periodontical management at the earliest
Patient education
 Proper brushing twice daily with super soft tooth brush.
INFLAMMATORY GINGIVAL ENLARGEMENTS
The gingival enlargement can be acute which is very painful or they can be chronic which
may be painless. There are many causes for gingival enlargements. Before giving treatment,
 Common in the age group of 13-25 years.
 Mobility in incisors and molars, spacing in upper incisors, distolabial migration of
upper incisors, arc shaped bone loss extending from distal surface of second premolar
to mesial surface of second molar.


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Dental Conditions
421
etiological factor must be evaluated.
Salient features
Pharmacologicaltreatment
 Tab. ciprofloxacin 500 mg 2 times a day for 3-5 days.
 Tab. diclofenac potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times a day for 3-5
days.
 Rinsing with 0.2% chlorhexidine mouthwash twice daily.
 Refer to a periodontist for surgical management and drainage of pus.
Patient education
 Proper brushing twice daily with super soft tooth brush.
 Shafer, Hine, Levy. In: A textbook of oral pathology. 4th Edition, Saunders, pp 782.
DENTAL FLUOROSIS
Salient features
Treatment
 Oral hygiene maintainance as patients are more caries susceptible
 Bleaching of teeth (Whitening of teeth)
 Veneers or laminates for better esthetics
TRIGEMINAL NEURALG IA


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 Bleaching of teeth (Whitening of teeth)
 Veneers or laminates for better esthetics
TRIGEMINAL NEURALG IA
It is sudden, sharp, severe or short duration, like electric shock like pain.
Salient features
Treatment
 Diagnostic dose of carbamazepine given to establish diagnosis
 Evaluation of any primary lesion in brain by MRI
 Acute enlargements may be localized or generalized, very painful, deep red in color,
soft friable with shiny surface.
 Chronic type may be localized or generalized, often painless and slowly progressive.
 Mainly seen in patients who are drinking fluorinated water (> 3PPM) during tooth
development time.
 White chalky/ brown spots on crowns of teeth
 Brownish discoloration on enamel mainly, involves anterior teeth & first molars


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development time.
 White chalky/ brown spots on crowns of teeth
 Brownish discoloration on enamel mainly, involves anterior teeth & first molars
 Presenceof trigger zones involving trigeminal nerve areas
 Unilateral sharp, shooting, lancinating type of pain may provoke on touch, washing
face, shaving, on cold wind exposure.
 Pain will be in recurrent bouts of attacks, may persist for second to minute


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Dental Conditions
422
 Tab. carbamazepine 200 mg. t.d.s as per intensity & frequency of pain & attacks.
 Refer to Dentists for further evaluation & treatment.
ORAL CANCER (HABIT RELATED DISEASE)
Oral cancer is most commonand associated with smokingand tobacco containing habit.
Adults are more commonly involved.
Salient features
Treatment
 Refer to Oncologist after thorough clinicaland histopathological examination.
 Advice symptomatic treatment if required.
ORAL SUBMUCUS FIBROSIS (OSMF)
Salient features
Treatment
 Quit habit as soon as possible, m outh opening exercises (physical exercises)
 Oral Hygiene prophylaxis
 Local medicaments in form of steroids
CYST OR TUMOR OF JAW
Salient features
 Long standing (> 2 weeks) non-healing chronic ulcer in oral cavity.Bleeding& non


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CYST OR TUMOR OF JAW
Salient features
 Long standing (> 2 weeks) non-healing chronic ulcer in oral cavity.Bleeding& non
painful ulcer or growth
 Regional lymphadenopathy,mobility or exfoliation of teeth.
 Decreased appetite, reduced weight, Poor Oral Hygiene, history of tobacco habit since
long time.Altered speech, difficulty in opening of mouth (Trismus)
 Most common disease related with tobacco, limeand Betelnut
 Gradually reduced mouth opening (Trismus)
 Blanching (White opaque)oral mucosa
 Recurrent ulcers & burning sensations on taking spicy food.
 Change of voice, difficulty in deglutition.
 Poor oral hygiene withgingivitis &periodontitis
 Small shrunken uvulaand decreased mobility of soft palate
 Facial asymmetry,Non tender swelling or growth,Paresthesia of jaw


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 Small shrunken uvulaand decreased mobility of soft palate
 Facial asymmetry,Non tender swelling or growth,Paresthesia of jaw
 Displacement of teeth, improper occlusion
 May be having discharge,Discoloration of teeth,Absence ofteeth in arch


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Dental Conditions
423
Treatment
 Refer to oral maxilla facial surgeon for bone fractures
GENERAL MEASURES FOR GOOD O RAL HYGIENE
 Select the right quality of tooth brush which should be short, soft and have uniformly
trimmed bristles. Change the brush at least after every 3 months
 Brush teeth at least twice a day for 2-3 minutes particularly at night before going to sleep.
 Use right technique of teeth brushing.Never use force while brushing.Use flossing at
least once a day.
 Avoid too much sugar and aerated drinks.Avoid eating in between meals, if cannot be
avoided rinse your mouth or preferably brush your teeth.
 Do notingest or swallow fluorinated toothpaste while brushing.
 Ensure regular dental checkup at 6 monthly interval.
ANTIBIOTIC PROPHYLAXIS IN DENTAL PROCEDURE


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 Ensure regular dental checkup at 6 monthly interval.
ANTIBIOTIC PROPHYLAXIS IN DENTAL PROCEDURE
 If patient is in the high or moderate risk groups, then antibiotic prophylaxis is
recommended for thefollowing dental procedures:
 Dental extractions.
 Periodontal procedures including surgery, scaling and root planing, probing, and recall
maintenance.
 Dental implant placement and reimplantation of avulsed teeth.
 Endodontic (root canal) instrumentation or surgery only beyond the apex.
 Sub gingival placement of antibiotic fibers or strips.
 Prophylactic cleaning of teeth or implants where bleeding is anticipated.
Antibiotic prophylaxis not recommended for the following dental procedures
 Restorative dentistry(operative and prosthodontic) with or without retraction cord.


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 Restorative dentistry(operative and prosthodontic) with or without retraction cord.
 Local anesthetic injections (nonintraligamentary). Intracanal endodontic treatment; post
placement and buildup.
 Placement of rubber dams, postoperative suture removal, taking of oral impressions, and
fluoride treatments.
 Placement of removable prosthodontic or orthodontic appliances and orthodontic
appliance adjustment.
 Taking of oral radiographs.
 Shedding of primary teeth.


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Abdominal aortic aneurysm | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Abdominal aortic aneurysm Abdominal aortic aneurysm About abdominal aortic aneurysms Symptoms of an abdominal aortic aneurysm Causes of an abdominal aortic aneurysm Diagnosing an abdominal aortic aneurysm Treating an abdominal aortic aneurysm Preventing an abdominal aortic aneurysm About abdominal aortic aneurysms An abdominal aortic aneurysm (AAA) is a swelling (aneurysm) of the aorta – the main blood vessel that leads away from the heart, down through the abdomen to the rest of the body. The abdominal aorta is the largest blood vessel in the body and is usually around 2cm wide – roughly the width of a garden hose. However, it can swell to over 5.5cm – what doctors class as a large AAA. Large aneurysms are rare, but can be very serious. If a large aneurysm bursts, it causes


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can swell to over 5.5cm – what doctors class as a large AAA. Large aneurysms are rare, but can be very serious. If a large aneurysm bursts, it causes huge internal bleeding and is usually fatal. The bulging occurs when the wall of the aorta weakens. Although what causes this weakness is unclear, smoking and high blood pressure are thought to increase the risk of an aneurysm. AAAs are most common in men aged over 65. A rupture accounts for more than 1 in 50 of all deaths in this group. This is why all men are invited for a screening test when they turn 65. The test involves a simple ultrasound scan, which takes around 10-15 minutes. Symptoms of an AAA In most cases, an AAA causes no noticeable symptoms. However, if it becomes large, some people may develop a pain or a pulsating feeling in their abdomen (tummy) or persistent back pain. An AAA doesn’t usually pose a serious threat to health, but there’s a risk that a larger aneurysm could burst (rupture). A ruptured aneurysm can cause


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AAA doesn’t usually pose a serious threat to health, but there’s a risk that a larger aneurysm could burst (rupture). A ruptured aneurysm can cause massive internal bleeding, which is usually fatal. Around 8 out of 10 people with a rupture either die before they reach hospital or don’t survive surgery. The most common symptom of a ruptured aortic aneurysm is sudden and severe pain in the abdomen. If you suspect that you or someone else has had a ruptured aneurysm, call 999 immediately and ask for an ambulance. Causes of an AAA It’s not known exactly what causes the aortic wall to weaken, although increasing age and being male are known to be the biggest risk factors. There are other risk factors you can do something about, including smoking and having high blood pressure and cholesterol level. Having a family history of aortic aneurysms also means that you have an increased risk of developing one yourself. Diagnosing an AAA Because AAAs usually cause no symptoms, they tend to be


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also means that you have an increased risk of developing one yourself. Diagnosing an AAA Because AAAs usually cause no symptoms, they tend to be diagnosed either as a result of screening or during a routine examination – for example, if a GP notices a pulsating sensation in your abdomen. The screening test is an ultrasound scan, which allows the size of your abdominal aorta to be measured on a monitor. This is also how an aneurysm will be diagnosed if your doctor suspects you have one. Treating an AAA If a large AAA is detected before it ruptures, most people will be advised to have treatment, to prevent it rupturing. This is usually done with surgery to replace the weakened section of the blood vessel with a piece of synthetic tubing. If surgery is not advisable – or if you decide not to have it – there are a number of non-surgical treatments that can reduce the risk of an aneurysm rupturing. They include medications to lower your cholesterol and blood pressure, and quitting smoking.


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that can reduce the risk of an aneurysm rupturing. They include medications to lower your cholesterol and blood pressure, and quitting smoking. You will also have the size of your aneurysm checked regularly with ultrasound scanning. Prevention The best way to prevent getting an aneurysm – or reduce the risk of an aneurysm growing bigger and possibly rupturing – is to avoid anything that could damage your blood vessels, such as: smoking eating a high-fat diet not exercising regularly being overweight or obese Screening Read more about screening for an AAA. Symptoms of an abdominal aortic aneurysm In most cases, an unruptured abdominal aortic aneurysm (AAA) will cause no symptoms, unless it becomes particularly large. Symptoms of an unruptured AAA may include: a pulsating feeling in your stomach (abdomen), usually near your belly button, that’s usually only noticeable when you touch it persistent back pain persistent abdominal pain If you have any of the symptoms above, you should see


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that’s usually only noticeable when you touch it persistent back pain persistent abdominal pain If you have any of the symptoms above, you should see your GP as soon as possible. Ruptured AAA If your aortic aneurysm ruptures, you will feel a sudden and severe pain in the middle or side of your abdomen. In men, the pain can also radiate down into the scrotum. Other symptoms include: dizziness sweaty and clammy skin rapid heartbeat (tachycardia) shortness of breath feeling faint loss of consciousness Medical emergency A ruptured aortic aneurysm is a medical emergency, and it’s important to get to hospital as soon as possible. Around 80% of people with a rupture die before they reach hospital or don’t survive emergency surgery. This is why the NHS AAA Screening Programme was introduced, so dangerously large aneurysms can be treated before they burst. If you suspect that you or someone in your care has had a ruptured aneurysm, call 999 immediately and ask for an ambulance. Causes of an


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they burst. If you suspect that you or someone in your care has had a ruptured aneurysm, call 999 immediately and ask for an ambulance. Causes of an abdominal aortic aneurysm The aorta is the largest blood vessel in the body. It transports oxygen-rich blood away from the heart to the rest of the body. An abdominal aortic aneurysm (AAA) occurs when part of the aorta wall becomes weakened and the large amount of blood that passes through it puts pressure on the weak spot, causing it to bulge outwards to form an aneurysm. The abdominal aorta is usually around 2cm wide – about the width of a garden hosepipe – but can swell to over 5.5cm, which is what doctors classify as a large aneurysm. Risk factors for an AAA It’s not known exactly what causes the aortic wall to weaken, although increasing age and being male are known to be the biggest risk factors. One study found that people aged over 75 are seven times more likely to be diagnosed with an AAA than people under 55 years old. Men are


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factors. One study found that people aged over 75 are seven times more likely to be diagnosed with an AAA than people under 55 years old. Men are around six times more likely to be diagnosed with an AAA than women. However, there are other risk factors that you can do something about – described below – the most important of which is smoking. Smoking Research has found that smokers are seven times more likely to develop an AAA than people who have never smoked. The more you smoke, the greater your risk of developing an AAA. People who regularly smoke more than 20 cigarettes a day may have more than 10 times the risk of non-smokers. The risk may increase because tobacco smoke contains harmful substances that can damage and weaken the wall of the aorta. Atherosclerosis Atherosclerosis is a potentially serious condition where arteries become clogged up by fatty deposits, such as cholesterol. An AAA is thought to develop because these deposits (called plaques) cause the aorta to widen in


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clogged up by fatty deposits, such as cholesterol. An AAA is thought to develop because these deposits (called plaques) cause the aorta to widen in an attempt to keep blood flowing through it. As it widens, it also gets weaker. Smoking, eating a high-fat diet and high blood pressure all increase your risk of developing atherosclerosis. High blood pressure As well as contributing to atherosclerosis, high blood pressure (hypertension) can place increased pressure on the aorta’s wall. Family history Having a family history of AAAs means that you have an increased risk of developing one. One study found that people who had a brother or sister with an AAA were eight times more likely to develop one than people whose siblings were unaffected. This suggests that certain genes you inherit from your parents may make you more vulnerable to developing an AAA. However, no specific genes have yet been identified. Diagnosing an abdominal aortic aneurysm An abdominal aortic aneurysm (AAA) usually


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an AAA. However, no specific genes have yet been identified. Diagnosing an abdominal aortic aneurysm An abdominal aortic aneurysm (AAA) usually causes no symptoms. Therefore, they tend to be diagnosed as a result of screening, or during a routine physical examination when a GP notices a distinctive pulsating sensation in your abdomen. A diagnosis can be confirmed using an ultrasound scan. Ultrasound can also determine the size of the aneurysm, which is an important factor in deciding on a course of treatment. Screening All men in the UK who are 65 or over are offered an ultrasound scan to check for AAAs. All men should receive an invitation in the year they turn 65 years old. Men who are older than 65 can refer themselves for screening by contacting their local NHS AAA screening service. For more information, visit our page on AAA screening. Treating an abdominal aortic aneurysm Treatment for an abdominal aortic aneurysm (AAA) depends on several factors, including the aneurysm’s size,


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Treating an abdominal aortic aneurysm Treatment for an abdominal aortic aneurysm (AAA) depends on several factors, including the aneurysm’s size, your age and general health. In general, if you have a large aneurysm (5.5cm or larger) you will be advised to have surgery, either to strengthen the swollen section of the aorta or to replace it with a piece of synthetic tubing. This is because the risk of the aneurysm rupturing is usually greater than the risk of having it repaired. If you have a small (3.0-4.4cm) or medium (4.5-5.4cm) aneurysm, you will be offered regular scans to check its size. You will also be given advice on how to slow its growth and reduce the risk of it rupturing – for example, stopping smoking – and perhaps medications to reduce your blood pressure and cholesterol level. If you have a large AAA If you are diagnosed with an AAA that is 5.5cm or larger, you will be referred to a vascular surgeon (a surgeon who specialises in diseases of the blood vessels), who may


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with an AAA that is 5.5cm or larger, you will be referred to a vascular surgeon (a surgeon who specialises in diseases of the blood vessels), who may recommend an operation. The surgeon will discuss treatment options with you, taking into account your general health and fitness, as well as the size of your aneurysm. If it’s decided that surgery isn’t suitable for you, it’s still possible to reduce the risk of the aneurysm bursting, and you will have regular scans to check its size – in the same way people with small or medium aneurysms are treated. See below for more information on treating small and medium aneurysms. There are two surgical techniques used to treat a large aneurysm: endovascular surgery open surgery Although both techniques are equally effective at reducing the risk of the aneurysm bursting, each has its own advantages and disadvantages. The surgeon will discuss with you which is most suitable. Endovascular surgery Endovascular surgery is a type of “keyhole” surgery


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and disadvantages. The surgeon will discuss with you which is most suitable. Endovascular surgery Endovascular surgery is a type of “keyhole” surgery where the surgeon makes small cuts in your groin. A small piece of tubing called a graft– made of metal mesh lined with fabric – is then guided up through the leg artery, into the swollen section of aorta, and sealed to the wall of the aorta at both ends. This reinforces the aorta, reducing the risk of it bursting. This is the safest of the two types of surgery available. Around 98-99% of patients make a full recovery, and recovery time from the operation is shorter than if you have open surgery. There are also fewer major complications, such as wound infection or deep vein thrombosis (DVT). However, the way the graft is attached is not as secure as open surgery. You’ll need regular scans to make sure the graft hasn’t slipped, and in some patients, the seal at each end of the graft starts to leak and will need to be resealed. You will


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to make sure the graft hasn’t slipped, and in some patients, the seal at each end of the graft starts to leak and will need to be resealed. You will need to have surgery again if either of these occurs. Open surgery In open surgery, the surgeon cuts into your stomach (abdomen) to reach the abdominal aorta and replaces the enlarged section with a graft. This type of graft is a tube made of a synthetic material. Because the graft is stitched (sutured) into place by the surgeon, it’s more likely to stay in place, and will usually work well for the rest of your life. The risk of complications linked to the graft after surgery is lower than in people who have endovascular surgery. Open surgery isn’t usually recommended for people who are in poor health as it is a major operation. It is slightly more risky than endovascular surgery, with 93-97% of patients making a full recovery. The main risk of open surgery is death or heart attack, and recovery time is longer than with endovascular


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93-97% of patients making a full recovery. The main risk of open surgery is death or heart attack, and recovery time is longer than with endovascular surgery. There is also a greater risk of complications, such as wound infection, chest infection and DVT. If you have a small or medium AAA If you are diagnosed with a small (3.0-4.4cm) or medium (4.5-5.4cm) aneurysm, you won’t be referred to see a vascular surgeon, as it’s unlikely you’d benefit from surgery. You’ll be invited back for regular scans to check the size of the aneurysm, in case it gets bigger – every year if you have a small aneurysm and every three months if you have a medium aneurysm. You will also be given advice on how to prevent the aneurysm from getting bigger, including: stopping smoking eating a balanced diet ensuring you maintain a healthy weight taking regular exercise If you smoke, the most important change you can make is to quit. Aneurysms have been shown to grow faster in smokers than in non-smokers. Read


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If you smoke, the most important change you can make is to quit. Aneurysms have been shown to grow faster in smokers than in non-smokers. Read more about stopping smoking and nicotine replacement therapies (NRTs) that can make it easier to stop smoking. Your GP will be sent your test result and may decide to change your current medication or start you on a new one, especially if you have: high blood pressure – which you will probably be treated for with a medication called an angiotensin-converting enzyme (ACE) inhibitor high cholesterol – which you will probably be treated for with a medication called a statin Treating a ruptured AAA Emergency treatment for a ruptured AAA is based on the same principle as preventative treatment. Grafts are used to repair the ruptured aneurysm. The decision on whether to perform open or endovascular surgery is made on a case-by-case basis by the surgeon carrying out the operation. Preventing an abdominal aortic aneurysm The best way to prevent getting


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is made on a case-by-case basis by the surgeon carrying out the operation. Preventing an abdominal aortic aneurysm The best way to prevent getting an aneurysm, or reduce the risk of an aneurysm growing bigger and possibly rupturing, is to avoid anything that could damage your blood vessels. This includes: smoking eating a high-fat diet not exercising regularly being overweight or obese If your GP finds out you have high blood pressure or a high cholesterol level, you may be prescribed medication for both. This will reduce the risk of developing an abdominal aortic aneurysm (AAA). Smoking Smoking is a major risk factor for aneurysms because it causes atherosclerosis (hardening of the arteries) and raises your blood pressure. Tobacco smoke contains substances that can damage the walls of the arteries. It is known that smokers are seven times more likely than non-smokers to develop an AAA. The more you smoke, the greater your risk. People who regularly smoke more than 20 cigarettes a day


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more likely than non-smokers to develop an AAA. The more you smoke, the greater your risk. People who regularly smoke more than 20 cigarettes a day may have more than 10 times the risk of non-smokers. If you want to stop smoking, your GP will be able to refer you to an NHS Stop Smoking Service, which will give you dedicated help and advice about the best ways to quit. You can also call or chat online with Quit Your Way Scotland. The specially trained helpline staff can offer you free expert advice and encouragement. Read more about stopping smoking and nicotine replacement therapies (NRTs), which can make it easier to quit. Diet Eating a high-fat diet increases your risk of atherosclerosis. It’s especially important to limit the amount of foods you eat that are high in saturated fat, such as biscuits, cakes, butter, sausages and bacon. This is because eating too much saturated fat can lead to high cholesterol, which can build up in the artery walls. Read more about high cholesterol.


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This is because eating too much saturated fat can lead to high cholesterol, which can build up in the artery walls. Read more about high cholesterol. Find out more about healthy eating and how to reduce the amount of saturated fat you eat. Exercise Being active and doing regular exercise lowers blood pressure by keeping your heart and blood vessels in good condition. Regular exercise can also help you lose weight, which will also help lower your blood pressure. Adults should do at least 150 minutes (two hours and 30 minutes) of moderate-intensity aerobic activity every week. Examples of moderate intensity activity include cycling or fast walking. For it to count, the activity should make you feel warm and slightly out of breath. Someone who is overweight may only have to walk up a slope to get this feeling. Physical activity can include anything from sport to walking and gardening. Weight Being overweight forces your heart to work harder to pump blood around your body. This can raise


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anything from sport to walking and gardening. Weight Being overweight forces your heart to work harder to pump blood around your body. This can raise your blood pressure, which in turn puts pressure on your arteries. Use a BMI healthy weight calculator to find out if you need to lose weight. If you need to shed some weight, it’s worth remembering that losing just a few pounds will make a big difference to your blood pressure and overall health. Get tips on losing weight safely Source: NHS 24 - Opens in new browser window Last updated: 04 October 2024 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform High blood pressure (hypertension) Other health sites Circulation Foundation: Abdominal aortic aneurysm NHS inform About


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For Me Also on NHS inform High blood pressure (hypertension) Other health sites Circulation Foundation: Abdominal aortic aneurysm NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/neck-and-back-problems-and-conditions/scoliosis/about-scoliosis/


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About scoliosis | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Muscle, bone and joints Neck and back problems and conditions Scoliosis About scoliosis About scoliosis Scoliosis is the abnormal twisting and curvature of the spine. Scoliosis can develop at any age, but is most common in children aged 10 to 15. Symptoms of scoliosis Scoliosis is usually first noticed by a change in the appearance of the back. Typical signs include: a visibly curved spine one shoulder being higher than the other one shoulder or hip being more prominent than the other clothes not hanging properly a prominent ribcage a difference in leg lengths People with scoliosis may also have back pain. This is more common in adults. When to get professional help If you or your child have signs of scoliosis, contact a healthcare professional. They can examine your back and decide


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When to get professional help If you or your child have signs of scoliosis, contact a healthcare professional. They can examine your back and decide the best next steps with you. Once you or your child has been diagnosed with scoliosis, you should see a specialist to talk about treatment options. Cauda equina syndrome Rarely scoliosis can cause a condition called cauda equina syndrome to develop. Cauda equina syndrome is serious back condition. It can lead to permanent damage or disability. If you develop this condition you’ll need to be seen by an emergency specialist spinal team. Phone 111 if: there has been a new, significant injury within the last 7 days, for example a fall from height or direct blow to the back Or you have experienced a new onset of the following symptoms: loss of feeling or pins and needles between your inner thighs or genitals numbness in or around your back passage or buttocks altered feeling when using toilet paper to wipe yourself increasing difficulty when


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or genitals numbness in or around your back passage or buttocks altered feeling when using toilet paper to wipe yourself increasing difficulty when you try to pee increasing difficulty when you try to stop or control your flow of pee loss of sensation when you pee leaking pee or a recent need to use pads not knowing when your bladder is either full or empty inability to stop a bowel motion or leaking loss of sensation when you poo change in ability to achieve an erection or ejaculate loss of sensation in genitals during sexual intercourse Causes of scoliosis In most cases, the cause of scoliosis is unknown and it cannot usually be prevented. This is called idiopathic scoliosis. About 80% of cases of scoliosis are idiopathic. It’s not thought to be linked with things like bad posture, exercise or diet. There is a family history of the condition in some idiopathic cases. This suggests a possible genetic link. Known causes of scoliosis Some cases of scoliosis are caused by conditions


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condition in some idiopathic cases. This suggests a possible genetic link. Known causes of scoliosis Some cases of scoliosis are caused by conditions that affect the nerves and muscles, like: cerebral palsy – a condition that affects the brain and nerves and happens during or shortly after birth muscular dystrophy – a genetic condition that causes muscle weakness neurofibromatosis – a genetic condition that causes benign tumours to grow along your nerves Congenital scoliosis In rare cases, babies can be born with scoliosis. This is known as congenital scoliosis. It’s caused by the bones in the spine not developing properly in the womb. Degenerative scoliosis In adults, scoliosis can sometimes be caused by age related changes to parts of the spine. This is known as degenerative scoliosis. Read more information on types of scoliosis from Scoliosis Support and Research Diagnosing scoliosis Scoliosis is first assessed by a healthcare professional with a physical examination of the spine,


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Support and Research Diagnosing scoliosis Scoliosis is first assessed by a healthcare professional with a physical examination of the spine, ribs, hips and shoulders. You may be asked to bend forward to see if any areas are particularly prominent. For example, one of your shoulders may be higher than the other or there may be a bulge in your back or ribs. After your assessment you may be referred to an spinal specialist. They will discuss further tests and treatments with you. Scans The specialist will usually take an X-ray to confirm the diagnosis of scoliosis. This will help determine the size and shape of the curve. In some cases, scans like a magnetic resonance imaging (MRI) scan or a computerised tomography (CT) scan can be recommended. Treatment of scoliosis Read about scoliosis treatment for children and young people Read about scoliosis treatment for adults Complications of scoliosis Scoliosis can sometimes lead to further emotional and physical problems. Having a visibly


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scoliosis treatment for adults Complications of scoliosis Scoliosis can sometimes lead to further emotional and physical problems. Having a visibly curved spine or wearing a back brace can cause problems related to body image, self-esteem and overall quality of life. This is particularly the case for children and teenagers with scoliosis. If this is a problem for you or your child, you may find it useful to contact a scoliosis support group, like the Scoliosis Association UK. These groups are a good source of information and support for people with scoliosis. Lung and heart problems In young children with severe scoliosis, the rib cage can be pushed against the heart and lungs. This can cause breathing problems and make it difficult for the heart to pump blood around the body. This can also increase the chances of developing lung infections, like pneumonia, and can lead to problems like heart failure. Nerve compression In some cases of scoliosis, particularly those affecting adults,


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like pneumonia, and can lead to problems like heart failure. Nerve compression In some cases of scoliosis, particularly those affecting adults, the bones in the spine compress nearby nerves. In severe cases, this can cause problems like: back and leg pain numbness or weakness in the legs Source: MSK Expert Panel - Opens in new browser window Last updated: 20 November 2024 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform Scoliosis treatment for children and young people Treating scoliosis in adults NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and


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about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/leg-and-foot-problems-and-conditions/achilles-tendinopathy/


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Achilles tendinopathy | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Muscle, bone and joints Leg and foot problems and conditions Achilles tendinopathy Achilles tendinopathy This information is useful for those who have been diagnosed with an Achilles tendinopathy. People who are experiencing new or ongoing symptoms should contact a healthcare professional for assessment and diagnosis. Read more about self-managing ankle problems What is Achilles tendinopathy? Achilles tendinopathy, sometimes known as tendinitis, is a condition that can cause pain, stiffness and swelling of the Achilles tendon. This is a tendon connecting your calf muscle to your heel. What are the symptoms of Achilles tendinopathy? Symptoms may vary from person to person. They can appear gradually or suddenly. People may experience: swelling pain that’s worse during or after


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Symptoms may vary from person to person. They can appear gradually or suddenly. People may experience: swelling pain that’s worse during or after moving or exercising stiffness that’s worse in the morning or after a period of rest tenderness to touch the affected area mild heat loss of movement and strength around the ankle and foot People can have one or multiple symptoms. What are the causes of Achilles tendinopathy? Achilles tendinopathy can occur in both active and inactive people. The causes can be varied but there are some common factors that are important.These can include: a sudden or gradual change in load, for example changes in the level of exercise or taking up a new sport, beyond your normal levels of strength or endurance spending a long time standing still wearing unsuitable or poorly fitting footwear for the activities you’re doing sedentary behaviour that can weaken your muscles and tendons over time smoking other health conditions such as being overweight, diabetes


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doing sedentary behaviour that can weaken your muscles and tendons over time smoking other health conditions such as being overweight, diabetes and inflammatory arthritis How to manage Achilles tendinopathy Managing Achilles tendinopathy can take time, in most cases several months or more. Learn about exercises for foot conditions To help manage the pain you can take painkillers. Read more about taking painkillers Achilles tendinopathy does not improve with rest, so, to help your recovery it’s important to keep up as much of your normal daily activity as you can. You may have to modify what you do, by taking breaks, doing less or changing activity. When you see a Healthcare Professional they will give guidance on what exercise levels you should be aiming for. If you’re waiting to see a Healthcare Professional you should be trying to do some exercise, this may cause some discomfort and short term pain that returns back to your normal level within a few hours. Help and support Following


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exercise, this may cause some discomfort and short term pain that returns back to your normal level within a few hours. Help and support Following this advice, you should see gradual improvements over time. If your symptoms haven’t improved within 12 weeks, or it’s got worse, after following this advice, it’s a good idea to talk to a healthcare professional about your symptoms. Find out how to access MSK services in your area. When dealing with any health condition it’s important to also look after your mental wellbeing as this can impact your recovery. Source: NHS 24 MSK Clinical Advisory Group - Opens in new browser window Last updated: 07 February 2025 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform Ankle problems


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Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform Ankle problems Exercises for calf and ankle problems NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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Acne | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Skin, hair and nails Acne Acne About acne Causes of acne Diagnosing acne Treating acne Complications of acne About acne Acne is a common skin condition that affects most people at some point. It causes spots, oily skin and sometimes skin that’s hot or painful to touch. Acne most commonly develops on the: face – this affects almost everyone with acne back – this affects more than half of people with acne chest – this affects about 15% of people with acne Types of spots There are 6 main types of spot caused by acne: blackheads – small black or yellowish bumps that develop on the skin; they’re not filled with dirt, but are black because the inner lining of the hair follicle produces pigmentation (colouring) whiteheads – have a similar appearance to blackheads, but may be firmer and won’t empty when


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of the hair follicle produces pigmentation (colouring) whiteheads – have a similar appearance to blackheads, but may be firmer and won’t empty when squeezed papules – small red bumps that may feel tender or sore pustules – similar to papules, but have a white tip in the centre, caused by a build-up of pus nodules – large hard lumps that build up beneath the surface of the skin and can be painful cysts – the most severe type of spot caused by acne; they’re large pus-filled lumps that look similar to boils and carry the greatest risk of causing permanent scarring Papules are small red bumps that may feel tender or sore.Source: https://dermnetnz.org/ Blackheads are small black or yellow lumps that form on the skin.Source: https://dermnetnz.org/ What can I do if I have acne? The self-help techniques below may be useful: Don’t wash affected areas of skin more than twice a day. Frequent washing can irritate the skin and make symptoms worse Wash the affected area with a mild soap or cleanser


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of skin more than twice a day. Frequent washing can irritate the skin and make symptoms worse Wash the affected area with a mild soap or cleanser and lukewarm water. Very hot or cold water can make acne worse Don’t try to “clean out” blackheads or squeeze spots. This can make them worse and cause permanent scarring Avoid using too much make-up and cosmetics. Use water-based products that are described as non-comedogenic (this means the product is less likely to block the pores in your skin) Completely remove make-up before going to bed If dry skin is a problem, use a fragrance-free, water-based emollient Regular exercise can’t improve your acne, but it can boost your mood and improve your self-esteem. Shower as soon as possible once you finish exercising, as sweat can irritate your acne Wash your hair regularly and try to avoid letting your hair fall across your face Although acne can’t be cured, it can be controlled with treatment. Several creams, lotions and gels for treating spots


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hair fall across your face Although acne can’t be cured, it can be controlled with treatment. Several creams, lotions and gels for treating spots are available at pharmacies. If you develop acne, it’s a good idea to speak to your pharmacist for advice. Treatments can take up to 3 months to work, so don’t expect results overnight. Once they do start to work, the results are usually good. When to get professional advice Acne isn’t usually serious and can be treated by a pharmacist. If your acne is severe or appears on your chest and back, it may need to be treated with antibiotics or stronger creams that are only available on prescription. Your pharmacist can advise on whether you need to see your GP for further treatment. If you develop nodules or cysts, they need to be treated properly through your GP to avoid scarring. Try to resist the temptation to pick or squeeze the spots, as this can lead to permanent scarring. Pharmacy First Scotland: Acne treatment from your pharmacyIf you


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the temptation to pick or squeeze the spots, as this can lead to permanent scarring. Pharmacy First Scotland: Acne treatment from your pharmacyIf you have acne you can get advice and treatment directly from a pharmacy. Find your local pharmacy on Scotland’s Service Directory.Search for a pharmacy near you Why do I have acne? Acne is most commonly linked to the changes in hormone levels during puberty, but can start at any age. Certain hormones cause the grease-producing glands next to hair follicles in the skin to produce larger amounts of oil (abnormal sebum). This abnormal sebum changes the activity of a usually harmless skin bacterium called P. acnes, which becomes more aggressive and causes inflammation and pus. The hormones also thicken the inner lining of the hair follicle, causing blockage of the pores (opening of the hair follicles). Cleaning the skin doesn’t help to remove this blockage. Other possible causes Acne is known to run in families. If both your mother and father


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Cleaning the skin doesn’t help to remove this blockage. Other possible causes Acne is known to run in families. If both your mother and father had acne, it’s likely that you’ll also have acne. Hormonal changes, such as those that occur during the menstrual cycle or pregnancy, can also lead to episodes of acne in women. There’s no evidence that diet, poor hygiene or sexual activity play a role in acne. Read more about the causes of acne, including some common acne myths. Who’s affected? Acne is very common in teenagers and younger adults. About 80% of people aged 11 to 30 are affected by acne. Acne is most common in girls from the ages of 14 to 17, and in boys from the ages of 16 to 19. Most people have acne on and off for several years before their symptoms start to improve as they get older. Acne often disappears when a person is in their mid-twenties. In some cases, acne can continue into adult life. About 5% of women and 1% of men have acne over the age of 25. Further information


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mid-twenties. In some cases, acne can continue into adult life. About 5% of women and 1% of men have acne over the age of 25. Further information You can find support and information from organisations like: Changing Faces – a charity for people who have a visible difference or facial disfigurement, who can be contacted on 0300 012 0275 for counselling and advice Causes of acne Acne is caused when tiny holes in the skin, known as hair follicles, become blocked. Sebaceous glands are tiny glands found near the surface of your skin. The glands are attached to hair follicles, which are small holes in your skin that an individual hair grows out of. Sebaceous glands lubricate the hair and the skin to stop it drying out. They do this by producing an oily substance called sebum. In acne, the glands begin to produce too much sebum. The excess sebum mixes with dead skin cells and both substances form a plug in the follicle. If the plugged follicle is close to the surface of the skin, it bulges


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mixes with dead skin cells and both substances form a plug in the follicle. If the plugged follicle is close to the surface of the skin, it bulges outwards, creating a whitehead. Alternatively, the plugged follicle can be open to the skin, creating a blackhead. Normally harmless bacteria that live on the skin can then contaminate and infect the plugged follicles, causing papules, pustules, nodules or cysts. Testosterone Teenage acne is thought to be triggered by increased levels of a hormone called testosterone, which occurs during puberty. The hormone plays an important role in stimulating the growth and development of the penis and testicles in boys, and maintaining muscle and bone strength in girls. The sebaceous glands are particularly sensitive to hormones. It’s thought that increased levels of testosterone cause the glands to produce much more sebum than the skin needs. Acne in families Acne can run in families. If your parents had acne, it’s likely that you’ll also develop it.


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much more sebum than the skin needs. Acne in families Acne can run in families. If your parents had acne, it’s likely that you’ll also develop it. One study has found that if both your parents had acne, you’re more likely to get more severe acne at an early age. It also found that if one or both of your parents had adult acne, you’re more likely to get adult acne too. Acne in women More than 80% of cases of adult acne occur in women. It’s thought that many cases of adult acne are caused by the changes in hormone levels that many women have at certain times. These times include: periods – some women have a flare-up of acne just before their period pregnancy – many women have symptoms of acne at this time, usually during the first 3 months of their pregnancy polycystic ovary syndrome – a common condition that can cause acne, weight gain and the formation of small cysts inside the ovary Other triggers Other possible triggers of an acne flare-up include: some cosmetic products – however,


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the formation of small cysts inside the ovary Other triggers Other possible triggers of an acne flare-up include: some cosmetic products – however, this is less common as most products are now tested, so they don’t cause spots (non-comedogenic) certain medications – such as steroid medications, lithium (used to treat depression and bipolar disorder) and some anti-epileptic drugs (used to treat epilepsy) regularly wearing items that place pressure on an affected area of skin, such as a headband or backpack smoking – which can contribute to acne in older people Acne myths Despite being one of the most widespread skin conditions, acne is also one of the most poorly understood. There are many myths and misconceptions about it: “Acne is caused by a poor diet” So far, research hasn’t found any foods that cause acne. Eating a healthy, balanced diet is recommended because it’s good for your heart and your health in general. “Acne is caused by having dirty skin and poor hygiene” Most of the


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diet is recommended because it’s good for your heart and your health in general. “Acne is caused by having dirty skin and poor hygiene” Most of the biological reactions that trigger acne occur beneath the skin, not on the surface, so the cleanliness of your skin has no effect on your acne. Washing your face more than twice a day could just aggravate your skin. “Squeezing blackheads, whiteheads and spots is the best way to get rid of acne” This could actually make symptoms worse and may leave you with scarring. “Sexual activity can influence acne” Having sex or masturbating won’t make acne any better or worse. “Sunbathing, sunbeds and sunlamps help improve the symptoms of acne” There’s no conclusive evidence that prolonged exposure to sunlight or using sunbeds or sunlamps can improve acne. Many medications used to treat acne can make your skin more sensitive to light, so exposure could cause painful damage to your skin, and also increase your risk of skin cancer. “Acne is infectious”


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skin more sensitive to light, so exposure could cause painful damage to your skin, and also increase your risk of skin cancer. “Acne is infectious” You can’t pass acne on to other people. Diagnosing acne Your pharmacist can diagnose acne by looking at your skin. This involves examining your face and possibly your chest and back for different types of spot, such as blackheads or sore, red nodules. How many spots you have and how painful and inflamed they are will help determine how severe your acne is. This is important in planning your treatment. 4 grades can be used to measure the severity of acne: grade 1 (mild) – acne is mostly confined to whiteheads and blackheads, with just a few papules and pustules grade 2 (moderate) – there are multiple papules and pustules, which are mostly confined to the face grade 3 (moderately severe) – there’s a large number of papules and pustules, as well as the occasional inflamed nodule, and the back and chest are also affected by acne grade 4


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– there’s a large number of papules and pustules, as well as the occasional inflamed nodule, and the back and chest are also affected by acne grade 4 (severe) – there’s a large number of large, painful pustules and nodules More severe acne can affect the back and neck.Source: https://dermnetnz.org/ Acne in women If acne suddenly starts in adult women, it can be a sign of a hormonal imbalance, especially if it’s accompanied by other symptoms such as: excessive body hair (hirsutism) irregular or light periods The most common cause of hormonal imbalances in women is polycystic ovary syndrome (PCOS). PCOS can be diagnosed using a combination of ultrasound scans and blood tests. Treating acne Treatment for acne depends on how severe it is. It can take several months of treatment before acne symptoms improve. The various treatments for acne are outlined below. If you just have a few blackheads, whiteheads and spots, you should be able to treat them successfully with over-the-counter gels or


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outlined below. If you just have a few blackheads, whiteheads and spots, you should be able to treat them successfully with over-the-counter gels or creams (topical treatments) that contain benzoyl peroxide. Treatments from your GP See your GP if your acne is more widespread, as you probably need prescription medication. For example, if: you have a large number of papules and pustules over-the-counter medication hasn’t worked Prescription medications that can be used to treat acne include: topical retinoids topical antibiotics azelaic acid antibiotic tablets in women, the combined oral contraceptive pill isotretinoin tablets If you have severe acne, your GP can refer you to an expert in treating skin conditions (dermatologist). For example, if you have: a large number of papules and pustules on your chest and back, as well as your face painful nodules A combination of antibiotic tablets and topical treatments is usually the first treatment option for severe acne. If this doesn’t work,


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nodules A combination of antibiotic tablets and topical treatments is usually the first treatment option for severe acne. If this doesn’t work, a medication called isotretinoin may be prescribed. Hormonal therapies or the combined oral contraceptive pill can also be effective in women who have acne. However, the progestogen-only pill or contraceptive implant can sometimes make acne worse. Many of these treatments can take 2 to 3 months before they start to work. It’s important to be patient and persist with a recommended treatment, even if there’s no immediate effect. Topical treatments (gels, creams and lotions) Benzoyl peroxide Benzoyl peroxide works as an antiseptic to reduce the number of bacteria on the surface of the skin. It also helps to reduce the number of whiteheads and blackheads, and has an anti-inflammatory effect. Benzoyl peroxide is usually available as a cream or gel. It’s used either once or twice a day. It should be applied 20 minutes after washing to all of the


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peroxide is usually available as a cream or gel. It’s used either once or twice a day. It should be applied 20 minutes after washing to all of the parts of your face affected by acne. It should be used sparingly, as too much can irritate your skin. It also makes your face more sensitive to sunlight, so avoid too much sun and ultraviolet (UV) light, or wear sun cream. Benzoyl peroxide can have a bleaching effect, so avoid getting it on your hair or clothes. Common side effects of benzoyl peroxide include: dry and tense skin a burning, itching or stinging sensation some redness and peeling of the skin Side effects are usually mild and should pass once the treatment has finished. Most people need a 6 week course of treatment to clear most or all of their acne. You may be advised to continue treatment less frequently to prevent acne returning. Topical retinoids Topical retinoids work by removing dead skin cells from the surface of the skin (exfoliating) which helps to prevent them


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Topical retinoids Topical retinoids work by removing dead skin cells from the surface of the skin (exfoliating) which helps to prevent them building up within hair follicles. Tretinoin and adapalene are topical retinoids used to treat acne. They’re available in a gel or cream and are usually applied once a day before you go to bed. Apply to all the parts of your face affected by acne 20 minutes after washing your face. It’s important to apply topical retinoids sparingly and avoid excessive exposure to sunlight and UV. Topical retinoids aren’t suitable for use during pregnancy, as there’s a risk they might cause birth defects. The most common side effects of topical retinoids are mild irritation and stinging of the skin. A 6 week course is usually required, but you may be advised to continue using the medication less frequently after this. Topical antibiotics Topical antibiotics help kill the bacteria on the skin that can infect plugged hair follicles. They’re available as a lotion or


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Topical antibiotics Topical antibiotics help kill the bacteria on the skin that can infect plugged hair follicles. They’re available as a lotion or gel that is applied once or twice a day. A 6 to 8 week course is usually recommended. After this, treatment is usually stopped, as there’s a risk that the bacteria on your face could become resistant to the antibiotics. This could make your acne worse and cause additional infections. Side effects are uncommon, but can include: minor irritation of the skin redness and burning of the skin peeling of the skin Azelaic acid Azelaic acid is often used as an alternative treatment for acne if the side effects of benzoyl peroxide or topical retinoids are particularly irritating or painful. Azelaic acid works by getting rid of dead skin and killing bacteria. It’s available as a cream or gel and is usually applied twice a day (or once a day if your skin is particularly sensitive). The medication doesn’t make your skin sensitive to sunlight, so you


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applied twice a day (or once a day if your skin is particularly sensitive). The medication doesn’t make your skin sensitive to sunlight, so you don’t have to avoid exposure to the sun. You’ll usually need to use azelaic acid for a month before your acne improves. The side effects of azelaic acid are usually mild and include: burning or stinging skin itchiness dry skin redness of the skin Antibiotic tablets Antibiotic tablets (oral antibiotics) are usually used in combination with a topical treatment to treat more severe acne. In most cases, a class of antibiotics called tetracyclines is prescribed, unless you’re pregnant or breastfeeding. Pregnant or breastfeeding women are usually advised to take an antibiotic called erythromycin, which is known to be safer to use. It usually takes about 6 weeks before you notice an improvement in your acne. Depending on how well you react to the treatment, a course of oral antibiotics can last 4 to 6 months. Tetracyclines can make your skin


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in your acne. Depending on how well you react to the treatment, a course of oral antibiotics can last 4 to 6 months. Tetracyclines can make your skin sensitive to sunlight and UV light, and can also make the oral contraceptive pill less effective during the first few weeks of treatment. You’ll need to use an alternative method of contraception, such as condoms, during this time. Hormonal therapies Hormonal therapies can often benefit women with acne, especially if the acne flares up around periods or is associated with hormonal conditions such as polycystic ovary syndrome. If you don’t already use it, your GP may recommend the combined oral contraceptive pill, even if you’re not sexually active. This combined pill can often help improve acne in women, but may take up to a year before the full benefits are seen. Co-cyprindiol Co-cyprindiol is a hormonal treatment that can be used for more severe acne that doesn’t respond to antibiotics. It helps to reduce the production of sebum.


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is a hormonal treatment that can be used for more severe acne that doesn’t respond to antibiotics. It helps to reduce the production of sebum. You’ll probably have to use co-cyprindiol for 2 to 6 months before you notice a significant improvement in your acne. There’s a small risk that women taking co-cyprindiol may develop breast cancer in later life. For example, out of a group of 10,000 women who haven’t taken co-cyprindiol, you would expect 16 of them to develop breast cancer by the time they were 35. This figure rises to 17 or 18 for women who were treated with co-cyprindiol for at least 5 years in their early twenties. There’s also a very small chance of co-cyprindiol causing a blood clot. The risk is estimated to be around 1 in 2,500 in any given year. It’s not thought to be safe to take co-cyprindiol if you’re pregnant or breastfeeding. Women may need to have a pregnancy test before treatment can begin. Other side effects of co-cyprindiol include: bleeding and spotting between


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Women may need to have a pregnancy test before treatment can begin. Other side effects of co-cyprindiol include: bleeding and spotting between your periods, which can sometimes occur for the first few months headaches sore breasts mood changes loss of interest in sex weight gain or weight loss Isotretinoin Isotretinoin has a number of beneficial effects: it helps to normalise sebum and reduce how much is produced it helps to prevent follicles becoming clogged it decreases the amount of bacteria on the skin it reduces redness and swelling in and around spots However, the drug can also cause a wide range of side effects. It’s only recommended for severe cases of acne that haven’t responded to other treatments. Because of the risk of side effects, isotretinoin can only be prescribed by a specially trained GP or a dermatologist. Isotretinoin is taken as a tablet. Most people take a 4 to 6 month course. Your acne may get worse during the first 7 to 10 days of treatment. However, this is


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is taken as a tablet. Most people take a 4 to 6 month course. Your acne may get worse during the first 7 to 10 days of treatment. However, this is normal and soon settles. Common side effects of isotretinoin include: inflammation, dryness and cracking of the skin, lips and nostrils changes in your blood sugar levels inflammation of your eyelids (blepharitis) inflammation and irritation of your eyes (conjunctivitis) blood in your urine Rarer side effects of isotretinoin include: inflammation of the liver (hepatitis) inflammation of the pancreas (pancreatitis) kidney disease Because of the risk of these rarer side effects, you’ll need a blood test before and during treatment. Isotretinoin and birth defects Isotretinoin will damage an unborn baby. If you’re a woman of childbearing age: don’t use isotretinoin if you’re pregnant or you think you’re pregnant use 1, or ideally 2, methods of contraception for 1 month before treatment begins, during treatment and for 1 month after treatment


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you’re pregnant use 1, or ideally 2, methods of contraception for 1 month before treatment begins, during treatment and for 1 month after treatment has finished have a pregnancy test before, during and after treatment You’ll be asked to sign a form confirming that you understand the risk of birth defects and are willing to use contraceptives to prevent this risk, even if you’re not currently sexually active. If you think you may have become pregnant when taking isotretinoin, contact your dermatologist immediately. Isotretinoin is also not suitable if you’re breastfeeding. Isotretinoin and mood changes There have been reports of people experiencing mood changes while taking isotretinoin. There’s no evidence that these mood changes were the result of the medication. However, as a precaution, contact your doctor immediately if you feel depressed or anxious, have feelings of aggression or suicidal thoughts. Non-pharmaceutical treatments Several treatments for acne don’t involve


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feel depressed or anxious, have feelings of aggression or suicidal thoughts. Non-pharmaceutical treatments Several treatments for acne don’t involve medication. These include: comedone extractor – a small pen-shaped instrument that can be used to clean out blackheads and whiteheads chemical peels – where a chemical solution is applied to the face, causing the skin to peel off and new skin to replace it photodynamic therapy – where light is applied to the skin in an attempt to improve symptoms of acne However, these treatments may not work and can’t be routinely recommended. Complications of acne Acne scarring can sometimes develop as a complication of acne. Any type of acne spot can lead to scarring, but it’s more common when the most serious types of spots (nodules and cysts) burst and damage nearby skin. Scarring can also occur if you pick or squeeze your spots, so it’s important not to do this. There are 3 main types of acne scars: ice pick scars – small, deep holes in the surface


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pick or squeeze your spots, so it’s important not to do this. There are 3 main types of acne scars: ice pick scars – small, deep holes in the surface of your skin that look like the skin has been punctured with a sharp object rolling scars – caused by bands of scar tissue that form under the skin, giving the surface of the skin a rolling and uneven appearance boxcar scars – round or oval depressions, or craters, in the skin Treating acne scarring Treatments for acne scarring are regarded as a type of cosmetic surgery, which isn’t usually available on the NHS. However, in the past, exceptions have been made when it’s been shown that acne scarring has caused serious psychological distress. See your GP if you’re considering having cosmetic surgery. They’ll be able to discuss your options with you and advise you about the likelihood of having the procedure carried out on the NHS. Many private clinics offer treatment for acne scarring. Prices can vary widely (from £500 to more than


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having the procedure carried out on the NHS. Many private clinics offer treatment for acne scarring. Prices can vary widely (from £500 to more than £10,000) depending on the type of treatment needed. The British Association of Plastic, Reconstructive and Aesthetic Surgeons website has more information about private treatment available in your area. It’s important to have realistic expectations about what cosmetic treatment can achieve. While treatment can certainly improve the appearance of your scars, it can’t get rid of them completely. After treatment for acne scarring, most people notice a 50-75% improvement in their appearance. Some of the available treatments for acne scarring are explained below. Dermabrasion Dermabrasion involves removing the top layer of skin, either using lasers or a specially made wire brush. After the procedure, your skin will look red and sore for several months, but as it heals you should notice an improvement in the appearance of your scars. Laser


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your skin will look red and sore for several months, but as it heals you should notice an improvement in the appearance of your scars. Laser treatment Laser treatment can be used to treat mild to moderate acne scarring. There are 2 types of laser treatment: ablative laser treatment – where lasers are used to remove a small patch of skin around the scar to produce a new, smooth-looking area of skin non-ablative laser treatment – where lasers are used to stimulate the growth of new collagen (a type of protein found in skin), which helps to repair some of the damage caused by scarring, and improves the appearance Punch techniques Punch techniques are used to treat ice pick scars and boxcar scars. There are 3 types of punch technique: punch excision – used to treat mild ice pick scars. The scar is surgically removed and the remaining wound is sealed. After the wound heals, it leaves a smoother and more even area of skin. punch elevation – used to treat boxcar scars. The base of the scar


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is sealed. After the wound heals, it leaves a smoother and more even area of skin. punch elevation – used to treat boxcar scars. The base of the scar is surgically removed, leaving the sides of the scar in place. The base is then reattached to the sides, but lifted up so it’s level with the surface of the skin. This makes the scar much less noticeable. punch grafting – used to treat very deep ice pick scars. As with a punch excision, the scar is removed, but the wound is “plugged” with a sample of skin taken from elsewhere on the body (usually from the back of the ear). Subcision Subcision is a surgical treatment that can be used to treat rolling scars. During surgery, the upper layer of the skin is removed from the underlying scar tissue. This allows blood to pool under the affected area. The blood clot helps form connective tissue, which pushes up the rolling scar so it’s level with the rest of the surface of the skin. Once subscision has been completed, additional treatment, such


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pushes up the rolling scar so it’s level with the rest of the surface of the skin. Once subscision has been completed, additional treatment, such as laser treatment and dermabrasion, can be used to further improve the appearance of the scar. Depression Acne can often cause intense feelings of anxiety and stress, which can sometimes make people with the condition become socially withdrawn. This combination of factors can lead to people with acne becoming depressed. You may be depressed if during the last month you’ve often felt down, depressed or hopeless, and have little interest or pleasure in doing things. If you think that you or your child may have depression, it’s important to speak to your GP. Treatments for depression include: talking therapies such as cognitive behavioural therapy (CBT) a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs) Read more about treatment for depression. Source: NHS 24 - Opens in new browser window Last updated: 01 May 2025


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reuptake inhibitors (SSRIs) Read more about treatment for depression. Source: NHS 24 - Opens in new browser window Last updated: 01 May 2025 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Other health sites British Association of Dermatologists British Skin Foundation Changing Faces Search for a pharmacy near you Enter a place or postcode NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/acute-cholecystitis/


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Acute cholecystitis | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Stomach, liver and gastrointestinal tract Acute cholecystitis Acute cholecystitis Acute cholecystitis is swelling (inflammation) of the gallbladder. It is a potentially serious condition that usually needs to be treated in hospital. The main symptom of acute cholecystitis is a sudden sharp pain in the upper right side of your tummy (abdomen) that spreads towards your right shoulder. The affected part of the abdomen is usually extremely tender, and breathing deeply can make the pain worse. Unlike some others types of abdominal pain, the pain associated with acute cholecystitis is usually persistent, and doesn’t go away within a few hours. Some people may additional symptoms, such as: a high temperature (fever) nausea and vomiting sweating loss of appetite yellowing of the skin and


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Some people may additional symptoms, such as: a high temperature (fever) nausea and vomiting sweating loss of appetite yellowing of the skin and the whites of the eyes (jaundice) a bulge in the abdomen When to seek medical advice Contact your GP practice if: you develop sudden and severe abdominal pain, particularly if the pain lasts longer than a few hours or you have other symptoms, such as jaundice and a fever If your GP practice is closed, phone 111. It’s important for acute cholecystitis to be diagnosed as soon as possible, because there is a risk that serious complications could develop if the condition is not treated promptly. What causes acute cholecystitis? The causes of acute cholecystitis can be grouped into 2 main categories: calculous cholecystitis and acalculous cholecystitis. Calculous cholecystitis Calculous cholecystitis is the most common, and usually less serious, type of acute cholecystitis. It accounts for around 95% of all cases. Calculous cholecystitis develops


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is the most common, and usually less serious, type of acute cholecystitis. It accounts for around 95% of all cases. Calculous cholecystitis develops when the main opening to the gallbladder, called the cystic duct, gets blocked by a gallstone or by a substance known as biliary sludge. Biliary sludge is a mixture of bile (a liquid produced by the liver that helps digest fats) and small crystals of cholesterol and salt. The blockage in the cystic duct results in a build-up of bile in the gallbladder, increasing the pressure inside it and causing it to become inflamed. In around 1 in every 5 cases, the inflamed gallbladder also becomes infected by bacteria. Acalculous cholecystitis Acalculous cholecystitis is a less common, but usually more serious, type of acute cholecystitis. It usually develops as a complication of a serious illness, infection or injury that damages the gallbladder. Acalculous cholecystitis is often associated with problems such as accidental damage to the gallbladder


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or injury that damages the gallbladder. Acalculous cholecystitis is often associated with problems such as accidental damage to the gallbladder during major surgery, serious injuries or burns, blood poisoning (sepsis), severe malnutrition or AIDS. Who is affected Acute cholecystitis is a relatively common complication of gallstones. It’s estimated that around 10% to 15% of adults in the UK have gallstones. These don’t usually cause any symptoms, but in a small proportion of people they can cause infrequent episodes of pain (known as biliary colic) or acute cholecystitis. Diagnosing cholecystitis To diagnose acute cholecystitis, your GP will examine your abdomen. They will probably carry out a simple test called Murphy’s sign. You will be asked to breathe in deeply with your GP’s hand pressed on your tummy, just below your rib cage. Your gallbladder will move downwards as your breathe in and, if you have cholecystitis, you will experience sudden pain as your gallbladder reaches your


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gallbladder will move downwards as your breathe in and, if you have cholecystitis, you will experience sudden pain as your gallbladder reaches your doctor’s hand. If your symptoms suggest you have acute cholecystitis, your GP will refer you to hospital immediately for further tests and treatment. Tests you may have in hospital include: blood tests to check for signs of inflammation in your body an ultrasound scan of your abdomen to check for gallstones or other signs of a problem with your gallbladder Other scans – such as an X-ray, a computerised tomography (CT) scan or a magnetic resonance imaging (MRI) scan – may also be carried out to examine your gallbladder in more detail if there is any uncertainty about your diagnosis. Treating acute cholecystitis If you are diagnosed with acute cholecystitis, you will probably need to be admitted to hospital for treatment. Initial treatment Initial treatment will usually involve: fasting (not eating or drinking) to take the strain off your


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to hospital for treatment. Initial treatment Initial treatment will usually involve: fasting (not eating or drinking) to take the strain off your gallbladder receiving fluids through a drip directly into a vein (intravenously) to prevent dehydration taking medication to relieve your pain If you have a suspected infection, you will also be given antibiotics. These often need to be continued for up to a week, during which time you may need to stay in hospital or you may be able to go home. With this initial treatment, any gallstones that may have caused the condition usually fall back into the gallbladder and the inflammation often settles down. Surgery In order to prevent acute cholecystitis recurring, and reduce your risk of developing potentially serious complications, the removal of your gallbladder will often be recommended at some point after the initial treatment. This type of surgery is known as a cholecystectomy. Although uncommon, an alternative procedure called a percutaneous


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after the initial treatment. This type of surgery is known as a cholecystectomy. Although uncommon, an alternative procedure called a percutaneous cholecystostomy may be carried out if you are too unwell to have surgery. This is where a needle is inserted through your abdomen to drain away the fluid that has built up in the gallbladder. If you are fit enough to have surgery, your doctors will need to decide when the best time to remove your gallbladder may be. In some cases, you may need to have surgery immediately or in the next day or 2, while in other cases you may be advised to wait for the inflammation to fully resolve over the next few weeks. Surgery can be carried out in two main ways: laparoscopic cholecystectomy – a type of keyhole surgery where the gallbladder is removed using special surgical instruments inserted through a number of small cuts (incisions) in your abdomen open cholecystectomy – where the gallbladder is removed through a single, larger incision in your


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a number of small cuts (incisions) in your abdomen open cholecystectomy – where the gallbladder is removed through a single, larger incision in your abdomen Although some people who have had their gallbladder removed have reported symptoms of bloating and diarrhoea after eating certain foods, you can lead a perfectly normal life without a gallbladder. The organ can be useful but it’s not essential, as your liver will still produce bile to digest food. Possible complications Without appropriate treatment, acute cholecystitis can sometimes lead to potentially life-threatening complications. The main complications of acute cholecystitis are: the death of the tissue of the gallbladder, called gangrenous cholecystitis, which can cause a serious infection that could spread throughout the body the gallbladder splitting open, known as a perforated gallbladder, which can spread the infection within your abdomen (peritonitis) or lead to a build-up of pus (abscess) In about 1 in every 5 cases of


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gallbladder, which can spread the infection within your abdomen (peritonitis) or lead to a build-up of pus (abscess) In about 1 in every 5 cases of acute cholecystitis, emergency surgery to remove the gallbladder is needed to treat these complications. Preventing acute cholecystitis It’s not always possible to prevent acute cholecystitis, but you can reduce your risk of developing the condition by cutting your risk of gallstones. One of the main steps you can take to help lower your chances of developing gallstones is adopting a healthy, balanced diet and reducing the number of high-cholesterol foods you eat, as cholesterol is thought to contribute to the formation of gallstones. Being overweight, particularly being obese, also increases your risk of developing gallstones. You should therefore control your weight by eating a healthy diet and exercising regularly. However, low-calorie, rapid weight loss diets should be avoided, because there is evidence they can disrupt your bile


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diet and exercising regularly. However, low-calorie, rapid weight loss diets should be avoided, because there is evidence they can disrupt your bile chemistry and actually increase your risk of developing gallstones. A more gradual weight loss plan is best. Read more about preventing gallstones. Source: NHS 24 - Opens in new browser window Last updated: 29 May 2023 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform Gallstones High cholesterol Self-help guide: Abdominal pain Other health sites NICE: single-incision laparoscopic cholecystectomy NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of


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inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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https://www.nhsinform.scot/illnesses-and-conditions/cancer/cancer-types-in-adults/acute-lymphoblastic-leukaemia/


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Acute lymphoblastic leukaemia | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Cancer Cancer types in adults Acute lymphoblastic leukaemia Acute lymphoblastic leukaemia About acute lymphoblastic leukaemia Symptoms of acute lymphoblastic leukaemia Causes of acute lymphoblastic leukaemia Diagnosing acute lymphoblastic leukaemia Treating acute lymphoblastic leukaemia Complications of acute lymphoblastic leukaemia About acute lymphoblastic leukaemia Leukaemia is cancer of the white blood cells. Acute leukaemia means the condition progresses rapidly and aggressively and requires immediate treatment. Acute leukaemia is classified according to the type of white blood cells affected by cancer. There are 2 main types: lymphocytes, which are mostly used to fight viral infections neutrophils, which perform several functions, such as fighting bacterial


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2 main types: lymphocytes, which are mostly used to fight viral infections neutrophils, which perform several functions, such as fighting bacterial infections, defending the body against parasites and preventing the spread of tissue damage These pages focus on acute lymphoblastic leukaemia, which is cancer of the lymphocytes. The following other types of leukaemia are covered elsewhere: chronic lymphocytic leukaemia chronic myeloid leukaemia acute myeloid leukaemia Warning signs of acute leukaemia Symptoms of acute lymphoblastic leukaemia usually begin slowly before rapidly getting severe as the number of immature white blood cells in your blood increases. Symptoms include: pale skin tiredness breathlessness having repeated infections over a short space of time unusual and frequent bleeding Read more about the symptoms of acute lymphoblastic leukaemia What happens in acute leukaemia All of the blood cells in the body are produced by bone marrow – a spongy material found inside bones.


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leukaemia What happens in acute leukaemia All of the blood cells in the body are produced by bone marrow – a spongy material found inside bones. Bone marrow produces specialised cells called stem cells which have the ability to develop into three important types of blood cells: red blood cells, which carry oxygen around the body white blood cells, which help fight infection platelets, which help stop bleeding The bone marrow usually produces stem cells which are allowed to fully develop before being released into the blood. But in acute leukaemia, bone marrow starts releasing large numbers of immature white blood cells known as blast cells. As the number of blast cells increases there is a drop in the number of red blood cells and platelet cells. This drop causes the symptoms of anaemia, such as tiredness, and increases the risk of excessive bleeding. Also, blast cells are less effective than mature white blood cells at fighting bacteria and viruses, making you more vulnerable to


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bleeding. Also, blast cells are less effective than mature white blood cells at fighting bacteria and viruses, making you more vulnerable to infection. Despite being uncommon overall, acute lymphoblastic leukaemia is the most common type of cancer to affect children. The cause or causes of acute leukaemia are uncertain, but known risk factors include: exposure to high levels of radiation exposure to benzene, a chemical used in manufacturing that is also found in cigarettes Read more information about the causes of acute lymphoblastic leukaemia Symptoms of acute lymphoblastic leukaemia Symptoms of acute lymphoblastic leukaemia usually begin slowly before rapidly getting severe as the number of blast cells (immature white blood cells) in your blood increases. Most of the symptoms are caused by the lack of healthy blood cells in your blood supply. Symptoms of acute lymphoblastic leukaemia include: pale skin feeling tired and breathless having repeated infections over a short space of


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supply. Symptoms of acute lymphoblastic leukaemia include: pale skin feeling tired and breathless having repeated infections over a short space of time unusual and frequent bleeding, such as bleeding gums or nose bleeds high temperature (fever) of 38C (100.4F) or above night sweats bone and joint pain easily bruised skin swollen lymph nodes (glands) abdominal pain – caused by a swollen liver or spleen unexplained weight loss a purple skin rash (purpura) In some cases of acute lymphoblastic leukaemia, the affected cells can spread from your bloodstream into your central nervous system. This can cause a series of neurological symptoms (related to the brain and nervous system), including: headaches seizures (fits) vomiting blurred vision dizziness When to seek medical advice If you or your child has some or even all of these symptoms, it is still highly unlikely that acute leukaemia is the cause. However, see your GP as soon as possible because any condition that causes these symptoms


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is still highly unlikely that acute leukaemia is the cause. However, see your GP as soon as possible because any condition that causes these symptoms needs to be promptly investigated and treated. Causes of acute lymphoblastic leukaemia Acute lymphoblastic leukaemia is caused by a DNA mutation in the stem cells causing too many white blood cells to be produced. The white blood cells are also released from the bone marrow before they are mature and able to fight infection like fully developed white blood cells. As the number of immature cells increases, the number of healthy red blood cells and platelets fall, and it’s this fall which causes many of the symptoms of leukaemia. It is not known exactly what causes this DNA mutation to occur, but there are a few factors which may increase the risk of developing acute lymphoblastic leukaemia. Risk factors Genetic disorders A small number of childhood acute lymphoblastic leukaemia cases are thought to be caused by related genetic disorders.


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Risk factors Genetic disorders A small number of childhood acute lymphoblastic leukaemia cases are thought to be caused by related genetic disorders. For example, rates of leukaemia tend to be higher in children with Down’s syndrome. Radiation exposure Exposure to very high levels of radiation, either before birth or afterwards, is a known risk factor. However, it would require a significant level of radiation, such as the amount released during the nuclear reactor accident at Chernobyl. Due to the potential risk of radiation to unborn babies, medical techniques and equipment that use radiation, such as X-rays, are rarely used on pregnant women. Most cases of childhood leukaemia occur in children with no history of genetic disorders or exposure to radiation. Possible environmental factors Experts have also carried out extensive research to determine whether the following environmental factors could be a trigger for leukaemia: living near a nuclear power station living near a power


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to determine whether the following environmental factors could be a trigger for leukaemia: living near a nuclear power station living near a power line living near a building or facility that releases electromagnetic radiation, such as a mobile phone mast At the moment there is no evidence to confirm that any of these environmental factors increase the risk of developing leukaemia. Benzene Exposure to the chemical benzene is a known risk factor for adult acute leukaemia. Benzene is found in petrol and is also used in the rubber industry. However, there are strict controls to protect people from prolonged exposure. Benzene is also found in cigarettes, which could explain why smokers are three times more likely to develop acute leukaemia than non-smokers. People who have had chemotherapy and radiotherapy to treat earlier, unrelated cancers also have an increased risk of developing acute leukaemia. Other risk factors There is some evidence to show an increased risk of acute lymphoblastic


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also have an increased risk of developing acute leukaemia. Other risk factors There is some evidence to show an increased risk of acute lymphoblastic leukaemia in people who: are obese have a weakened immune system – due to HIV or AIDS or taking immunosuppressants after an organ transplant Diagnosing acute lymphoblastic leukaemia The first step in diagnosing acute lymphoblastic leukaemia is for your GP to check for physical signs of the condition, such as swollen glands, and to take a blood sample. A high number of abnormal white blood cells in the blood sample could indicate the presence of acute leukaemia and you will then be referred to a haematologist (a specialist in treating blood conditions). Bone marrow biopsy To confirm a diagnosis of acute leukaemia, the haematologist will take a small sample of your bone marrow to examine under a microscope. The haematologist will use a local anaesthetic to numb the skin over a bone – usually the hip bone – and then use a needle to remove a


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a microscope. The haematologist will use a local anaesthetic to numb the skin over a bone – usually the hip bone – and then use a needle to remove a sample of bone marrow. You may experience some pain once the anaesthetic wears off and some bruising and discomfort for a few days afterwards. The procedure takes around 15 minutes to complete and you shouldn’t have to stay in hospital overnight. The bone marrow will be checked for cancerous cells and – if found – the type of acute leukaemia will be determined at the same time. Further tests There are various additional tests that can be used to help reveal more information about the progress and extent of the leukaemia. They can also provide an insight into how the leukaemia should be treated. These tests are described below. Cytogenetic testing Cytogenetic testing involves identifying the genetic make-up of the cancerous cells. There are specific genetic variations that can occur during leukaemia, and knowing what these variations are


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genetic make-up of the cancerous cells. There are specific genetic variations that can occur during leukaemia, and knowing what these variations are can have an important impact on treatment. Immunophenotyping Immunophenotyping is a test to help identify the exact type of acute lymphoblastic leukaemia. A sample of blood, bone marrow or another type of fluid is studied. This testing is important as the treatment needed may be slightly different for each type. Polymerase chain reaction (PCR) A polymerase chain reaction (PCR) test can be done on a blood sample. This is an important test to diagnose and monitor the response to treatment. The blood test is repeated every three months for at least two years after starting treatment, then less often once remission is achieved. Lymph node biopsy If you have been diagnosed with acute leukaemia, further biopsies may be carried out on any enlarged lymph nodes that you have. These will be able to establish how far the leukaemia has spread. CT


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further biopsies may be carried out on any enlarged lymph nodes that you have. These will be able to establish how far the leukaemia has spread. CT scans If you have acute leukaemia, a computerised tomography scan (CT scan) may be used to check that your organs, such as your heart and lungs, are healthy. Chest X-ray An X-ray may be performed to examine the chest for any swollen lymph nodes. Lumbar puncture If it is felt that there is a risk that acute leukaemia has spread to your nervous system, a lumbar puncture may be carried out. A lumbar puncture is a test where a needle is used under local anaesthetic to extract a sample of cerebrospinal fluid (fluid that surrounds and protects your spine) from your back. The fluid is tested to determine whether the leukaemia has reached your nervous system. Treating acute lymphoblastic leukaemia Treatment for acute lymphoblastic leukaemia usually begins a few days after diagnosis as it’s an aggressive condition that develops rapidly. Stages of


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for acute lymphoblastic leukaemia usually begins a few days after diagnosis as it’s an aggressive condition that develops rapidly. Stages of treatment Treatment for acute lymphoblastic leukaemia is carried out in stages: induction – the aim of the initial stage of treatment is to kill the leukaemia cells in your bone marrow, restore the balance of cells in your blood and resolve any symptoms you may have consolidation – this stage aims to kill any remaining leukaemia cells in your central nervous system maintenance – the final stage involves taking regular doses of chemotherapy tablets to prevent the leukaemia returning Maintenance only seems to be effective in treating acute lymphoblastic leukaemia; it’s not usually used in the treatment of acute myeloid leukaemia. Induction The induction stage of treatment is carried out in hospital or in a specialist centre. This is because you will probably need to have regular blood transfusions as it’s likely that your blood will not contain


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or in a specialist centre. This is because you will probably need to have regular blood transfusions as it’s likely that your blood will not contain enough healthy blood cells. You will also be vulnerable to infection, so it is important that you are in a sterile environment where your health can be carefully monitored and any infection that you have can be promptly treated. You may also be prescribed antibiotics to help prevent further infection. Chemotherapy You will be given chemotherapy to kill the leukaemia cells in your bone marrow. Although some medications may be given as pills, you will need more than one medication given as an injection. To make things easier and avoid repeated injections, they can all be given via one flexible tube into a vein in your chest (called a central line). Some chemotherapy medication may also be directly administered into your cerebrospinal fluid to kill any leukaemia cells that may have spread to your nervous system. This is given using a needle


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administered into your cerebrospinal fluid to kill any leukaemia cells that may have spread to your nervous system. This is given using a needle that is placed into your spine, in a similar way to a lumbar puncture. Side effects that occur following chemotherapy are common. They can include: nausea vomiting diarrhoea loss of appetite mouth ulcers tiredness skin rashes infertility hair loss The side effects should resolve once treatment has finished. Your hair will usually take between three to six months to grow back. Steroid therapy You may also be given corticosteroid injections or tablets to help improve the effectiveness of chemotherapy. Imatinib If you have a type of leukaemia known as Philadelphia chromosome-positive acute lymphoblastic leukaemia, you will also be given a medicine called imatinib. Imatinib works by blocking the signals in the cancerous cells that cause them to grow and reproduce. This kills the cancerous cells. Imatinib is taken orally (as a tablet). The side


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in the cancerous cells that cause them to grow and reproduce. This kills the cancerous cells. Imatinib is taken orally (as a tablet). The side effects of imatinib are usually mild and should improve over time. They include: nausea vomiting swelling in the face and lower legs muscle cramps rash diarrhoea Depending on how well you respond to treatment, the induction phase can last from two weeks to several months. In some cases, you or your child may be able to leave hospital and receive treatment on an outpatient basis if your symptoms improve. Consolidation Leukaemia can return if just one cancerous cell remains in your body. Therefore the aim of consolidation treatment is to ensure that any remaining leukaemia cells are killed. Treatment involves receiving regular injections of chemotherapy medication. This is usually done on an outpatient basis, which means you will not have to stay in hospital overnight. However, you may require some short stays in hospital if your symptoms


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outpatient basis, which means you will not have to stay in hospital overnight. However, you may require some short stays in hospital if your symptoms suddenly get worse or if you develop an infection. The consolidation phase of treatment lasts several months. Maintenance The maintenance phase is designed to act as further insurance against the possibility of the leukaemia returning. It involves taking regular doses of chemotherapy tablets while undergoing regular check-ups to monitor how effective your treatment is proving. The maintenance phase can often last for two years. Other treatments As well as chemotherapy and imatinib, other treatments are used in some circumstances. These are described below. Dasatinib Dasatinib is a new type of medication used to treat Philadelphia chromosome-positive acute lymphoblastic leukaemia, when all other treatments have proved unsuccessful. Dasatinib blocks a protein called tyrosine kinase that helps stimulate the growth of cancer cells. Dasatinib


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treatments have proved unsuccessful. Dasatinib blocks a protein called tyrosine kinase that helps stimulate the growth of cancer cells. Dasatinib cannot cure acute leukaemia but it can slow its growth, helping to relieve symptoms and prolong life. The National Institute for Health and Care Excellence (NICE) has not yet made a decision about whether the NHS should provide treatment with dasatinib for people with acute lymphoblastic leukaemia. This means it will be at the discretion of your local clinical commissioning group as to whether you will be offered the drug. Radiotherapy Radiotherapy involves using high doses of controlled radiation to kill cancerous cells. There are two main reasons why radiotherapy is usually used to treat acute leukaemia: to sometimes treat advanced cases of acute lymphoblastic leukaemia that have spread to the nervous system or brain to prepare the body for a bone marrow transplant (see below) Side effects of both types of radiotherapy include: hair loss


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nervous system or brain to prepare the body for a bone marrow transplant (see below) Side effects of both types of radiotherapy include: hair loss nausea fatigue The side effects should pass once your course of radiotherapy has been completed. However, your skin may be very sensitive to the effects of light for several months after the treatment has finished. If this is the case, avoid sunbathing or exposure to sources of artificial light, such as sunbeds, for several months. Many younger children treated with radiotherapy will go on to have restricted physical growth during puberty. A small number of people develop cataracts several years after radiotherapy. Cataracts are cloudy patches in the lens (the transparent structure at the front of the eye) that can make your vision blurred or misty. Cataracts can usually be successfully treated using surgery. Read more about cataracts Bone marrow and stem cell transplants If you or your child do not respond to chemotherapy, a possible


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using surgery. Read more about cataracts Bone marrow and stem cell transplants If you or your child do not respond to chemotherapy, a possible alternative treatment option is bone marrow or stem cell transplantation. Transplantations are more successful if the donor has the same tissue type as you, so the ideal donor is usually a brother or sister. Before transplantation can take place, the person receiving the transplant will need to have aggressive high-dose chemotherapy and radiotherapy to destroy any cancerous cells in their body. This can put a big strain on the body so transplantations are usually only successful when they are carried out in children and young people, or older people who are in good health, and when there is a suitable donor, such as a brother or sister. Read about bone marrow transplantation for more information Complications of acute lymphoblastic leukaemia Being immunocompromised (having a weakened immune system) is a possible complication for some patients


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Complications of acute lymphoblastic leukaemia Being immunocompromised (having a weakened immune system) is a possible complication for some patients with acute leukaemia. There are 2 reasons for this: the lack of healthy white blood cells means that your immune system is less able to fight infection many of the medicines used to treat acute leukaemia can weaken the immune system This means that you are more vulnerable to developing an infection, and that any infection you have has an increased potential to cause serious complications. You may be advised to take regular doses of antibiotics to prevent infections occurring. You should immediately report any possible symptoms of an infection to your GP or care team because prompt treatment may be required to prevent serious complications. Symptoms of infection include: high temperature (fever) of 38C (101.4F) or above headache aching muscles diarrhoea tiredness Avoid contact with anyone who is known to have an infection, even if it is a


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of 38C (101.4F) or above headache aching muscles diarrhoea tiredness Avoid contact with anyone who is known to have an infection, even if it is a type of infection that you were previously immune to, such as chickenpox or measles. This is because your previous immunity to these conditions will probably be lower. While it is important to go outside on a regular basis, both for exercise and for your psychological wellbeing, avoid visiting crowded places and using public transport during rush hour. Also ensure that all of your vaccinations are up-to-date. Your GP or care team will be able to advise you about this. You will be unable to have any vaccine containing activated particles of viruses of bacteria such as: the mumps, measles and rubella (MMR) vaccine the polio vaccine the oral typhoid vaccine the BCG vaccine (used to vaccinate against tuberculosis) the yellow fever vaccine Bleeding If you have acute leukaemia, you will bleed and bruise more easily due to the low levels of


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against tuberculosis) the yellow fever vaccine Bleeding If you have acute leukaemia, you will bleed and bruise more easily due to the low levels of platelets (clot-forming cells) in your blood. Bleeding may also be excessive when it does occur. Bleeding can occur: inside the skull (intracranial haemorrhage) inside the lungs (pulmonary haemorrhage) inside the stomach (gastrointestinal haemorrhage) The symptoms of an intracranial haemorrhage include: severe headache stiff neck vomiting change in mental state, such as confusion The most common symptoms of a pulmonary haemorrhage are: coughing up blood from your nose and mouth breathing difficulties a bluish skin tone (cyanosis) The 2 most common symptoms of a gastrointestinal haemorrhage are: vomiting blood passing stools (faeces) that are very dark or tar-like All 3 types of haemorrhages should be regarded as medical emergencies. Phone 999 to request an ambulance if you suspect that you or your child is experiencing a haemorrhage.


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should be regarded as medical emergencies. Phone 999 to request an ambulance if you suspect that you or your child is experiencing a haemorrhage. Infertility Many of the treatments that are used to treat acute leukaemia can cause infertility. Infertility is often temporary, although in some cases it may be permanent. People who are particularly at risk of becoming infertile are those who have received high doses of chemotherapy and radiotherapy in preparation for bone marrow or stem cell transplantation. It may be possible to guard against any risk of infertility before you begin your treatment. For example, men can have samples of their sperm stored. Similarly, women can have fertilised embryos stored, which can then be placed back into their womb following treatment. Read more about infertility Psychological effects of leukaemia Receiving a diagnosis of leukaemia can be very distressing, particularly if it is unlikely that your condition can be cured. At first, the news may be


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a diagnosis of leukaemia can be very distressing, particularly if it is unlikely that your condition can be cured. At first, the news may be difficult to take in. The situation can be made worse if you are confronted with the knowledge that even though your leukaemia may not currently be causing any symptoms, it could be a serious problem in later life. Having to wait many years to see how the leukaemia develops can be immensely stressful and can trigger feelings of stress, anxiety and depression. If you have been diagnosed with leukaemia, talking to a counsellor or psychiatrist (a doctor who specialises in treating mental health conditions) may help you to combat feelings of depression and anxiety. Antidepressants or medicines that help to reduce feelings of anxiety may also help you cope better with the condition. You may find it useful to talk to other people who are living with leukaemia. Your GP or multidisciplinary team may be able to provide you with details of local support


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to talk to other people who are living with leukaemia. Your GP or multidisciplinary team may be able to provide you with details of local support groups. Another excellent resource is Macmillan Cancer Support. Their helpline number is 0808 808 00 00 and is open Monday to Friday, 9am to 8pm. Further information You can read more information on all aspects of living and coping with cancer at the following links: living with cancer – including information on treatment, support and personal experiences of cancer living with acute lymphoblastic leukaemia – Cancer Research UK Source: NHS 24 - Opens in new browser window Last updated: 09 January 2025 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform Acute myeloid leukaemia


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Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform Acute myeloid leukaemia Chronic myeloid leukaemia Other health sites Anthony Nolan Blood Cancer UK: Understanding blood cancer Cancer Research UK: Acute lymphoblastic leukaemia Children with Cancer Macmillan Cancer Support: Leukaemia Scottish Cancer Network: Patient information Search for cancer support services near you Enter a place or postcode NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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Acute lymphoblastic leukaemia: Children | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Cancer Cancer types in children Acute lymphoblastic leukaemia: Children Acute lymphoblastic leukaemia: Children Acute lymphoblastic leukaemia (ALL) is a type of blood cancer. One third of all childhood cancers are leukaemia. Approximately, 3 out of 4 of these are acute lymphoblastic (ALL). ALL can affect children of any age but is more common in children aged 1 to 4 years old. More children than ever are surviving childhood cancer. There are new and better drugs and treatments, and we can now also work to reduce the after-effects of having had cancer in the past. It’s devastating to hear that your child has cancer. At times it can feel overwhelming but there are many healthcare professionals and support organisations to help you through this difficult time.


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At times it can feel overwhelming but there are many healthcare professionals and support organisations to help you through this difficult time. Understanding more about the cancer your child has and the treatments that may be used can often help parents to cope. Your child’s specialist will give you more detailed information, and if you have any questions it’s important to ask the specialist doctor or nurse who knows your child’s individual situation. Leukaemia Leukaemia is a cancer of the white blood cells. All blood cells are made in the bone marrow, the spongy substance at the core of some bones in the body. Bone marrow contains: red blood cells, which carry oxygen around the body platelets, which help the blood to clot and control bleeding white blood cells, which help fight infection There are 2 different types of white blood cells: lymphocytes and myeloid cells (including neutrophils). These white blood cells work together to fight infection. Normally, white blood cells


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cells: lymphocytes and myeloid cells (including neutrophils). These white blood cells work together to fight infection. Normally, white blood cells develop, repair and reproduce themselves in an orderly and controlled way. In leukaemia, however, the process gets out of control and the cells continue to divide in the bone marrow, but do not mature. These immature dividing cells fill up the bone marrow and stop it from making healthy blood cells. As the leukaemia cells are not mature, they cannot work properly. This leads to an increased risk of infection. There are 4 main types of leukaemia: acute lymphoblastic (ALL) acute myeloid (AML) chronic lymphocyte (CLL) chronic myeloid (CML) Chronic leukaemias usually affect adults and each type of leukaemia has its own characteristics and treatment. ALL is a cancer of immature lymphocytes, called lymphoblasts or blast cells. There are two different types of lymphocytes; T-cells and B-cells. Often, leukaemia occurs at a very early stage in the


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lymphoblasts or blast cells. There are two different types of lymphocytes; T-cells and B-cells. Often, leukaemia occurs at a very early stage in the immature lymphocytes, before they have developed into either T-cells or B-cells. However, if the cells have developed this far before becoming leukaemic, the type of leukaemia may be known as T-cell or B-cell leukaemia. This page is about acute lymphoblastic leukaemia (ALL). Causes The exact cause of ALL is unknown. Research is going on all the time into possible causes of this disease. Children with certain genetic disorders, such as Down’s syndrome, are known to have a higher risk of developing leukaemia. Brothers and sisters of a child with ALL (particularly identical twins) have a slightly increased risk of developing ALL themselves, although this risk is still small. Like all cancers, ALL is not infectious and cannot be passed on to other people. Signs and symptoms As the leukaemia cells multiply in the bone marrow, the production of


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is not infectious and cannot be passed on to other people. Signs and symptoms As the leukaemia cells multiply in the bone marrow, the production of normal blood cells is reduced. Children may therefore become tired and lethargic because of anaemia, which is caused by a lack of red blood cells. Children may develop bruises, and bleeding may take longer to stop because of the low number of platelets present in their blood (which help blood to clot). Sometimes, children suffer from infections because of low numbers of normal white blood cells. A child is likely to feel generally unwell and may complain of aches and pains in the limbs or may have swollen lymph glands. At first, the symptoms are just like those of a viral infection, but when they continue for more than a week or two, the diagnosis usually becomes clear. How ALL is diagnosed A blood test usually shows low numbers of normal white blood cells and the presence of the abnormal leukaemia cells. A sample of bone marrow is usually


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blood test usually shows low numbers of normal white blood cells and the presence of the abnormal leukaemia cells. A sample of bone marrow is usually needed to confirm the diagnosis. A sample is also sent to the genetics department to look for any abnormal chromosomes, and for a test called MRD (minimal residual disease) analysis. A test called a lumbar puncture is done to see if the spinal fluid contains any leukaemia cells. A chest X-ray is also done, which will show if there are any enlarged glands in the chest. Other tests may be necessary, depending on your child’s symptoms. These tests will help to identify the precise type of leukaemia and help doctors decide on the best treatment. Treatment The aim of treatment for ALL is to destroy the leukaemia cells and enable the bone marrow to work normally again. Chemotherapy is the main treatment for ALL and is given according to a treatment plan (often called a protocol or regimen). The treatment is given in several phases, or


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main treatment for ALL and is given according to a treatment plan (often called a protocol or regimen). The treatment is given in several phases, or ‘blocks’. Induction This phase involves intensive treatment, aimed at destroying as many leukaemia cells as possible and is usually started within days of being diagnosed. The induction phase lasts 4 to 6 weeks. A bone marrow test is taken at the end of induction treatment to confirm whether or not the child still has leukaemia. The sample that is taken is looked at under a microscope and when there is no evidence of leukaemia, the child’s condition is referred to as being in ‘remission’. Consolidation and central nervous system (CNS) treatment The next phase of treatment is aimed at maintaining the remission and preventing the spread of leukaemia cells into the brain and spinal cord (the central nervous system, or CNS). CNS treatment involves injecting a drug, usually methotrexate lumbar puncture. After this consolidation treatment there


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nervous system, or CNS). CNS treatment involves injecting a drug, usually methotrexate lumbar puncture. After this consolidation treatment there is a recovery period which is called interim maintenance. This is when more drugs will be given to try to keep the leukaemia in remission. The exact details will depend on which arm of treatment your child follows and will be discussed in detail by your child’s doctor as it depends on your child’s response to treatment so far. Further doses of chemotherapy treatment, called ‘delayed intensification’, are given to kill off any remaining leukaemia cells. Maintenance treatment This phase of treatment lasts for 2 years from the start of interim maintenance for girls and 3 years from the start of interim maintenance for boys. It involves the child taking daily and weekly tablets, some children also have monthly injections of chemotherapy and oral pulses of steroids and 3-monthly intrathecal treatment. Children will be able to take part in their


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have monthly injections of chemotherapy and oral pulses of steroids and 3-monthly intrathecal treatment. Children will be able to take part in their normal daily activities as soon as they feel able to. Most children return to school before beginning maintenance treatment. Bone marrow transplantation Bone marrow treatment is only needed by a minority of patients and is used for children with ALL that is likely to come back following standard chemotherapy. Testicular radiotherapy In some situations, it may be necessary for boys to have radiotherapy to their testicles. This is because leukaemia cells can survive in the testicles despite chemotherapy. Central nervous system (CNS) radiotherapy Children who have leukaemia cells in their CNS when they are first diagnosed with ALL need more frequent lumbar punctures with intrathecal chemotherapy. Your child’s specialist will discuss with you which treatment and how much of it your child needs, and will answer any questions you have. Side


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Your child’s specialist will discuss with you which treatment and how much of it your child needs, and will answer any questions you have. Side effects of treatment Many cancer treatments will cause side effects. This is because while the treatments are killing the cancer cells, they can also damage some normal cells. Some of the main side effects of chemotherapy are: hair loss reduction in the number of blood cells produced by the bone marrow, which can cause anaemia (increased risk of bruising, bleeding and infection loss of appetite feeling sick (nausea) and being sick (vomiting) Steroid medicines can also cause side effects such as: increased appetite mood changes and irritability weight gain muscle weakness (especially in the legs) Most side effects are temporary, and there are ways of reducing them and supporting your child through them. Your child’s doctor or nurse will talk to you about any possible side effects. It’s important to discuss any side effects your child is having


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them. Your child’s doctor or nurse will talk to you about any possible side effects. It’s important to discuss any side effects your child is having with the team treating them, so that they know how your child is feeling. Late side effects of treatment A small number of children may develop late side effects, sometimes many years later. These include possible problems with puberty and fertility, a change in the way their heart works and a small increase in the risk of developing another cancer later in life. Your child’s doctor or nurse will talk to you about any possible late side effects. Clinical trials Many children have their treatment as part of a clinical research trial. Trials aim to improve our understanding of the best way to treat an illness, usually by comparing the standard treatment with a new or modified version. Specialist doctors carry out trials for ALL. If appropriate, your child’s medical team will talk to you about taking part in a clinical trial and will answer


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doctors carry out trials for ALL. If appropriate, your child’s medical team will talk to you about taking part in a clinical trial and will answer any questions you have. Written information is provided to help explain things. Taking part in a research trial is completely voluntary, and you’ll be given enough time to decide if it is right for your child. Treatment guidelines Sometimes, clinical trials are not available for your child. This may be because a recent trial has just finished, or because the condition is very rare. In these cases, you can expect your doctors and nurses to offer treatment which is agreed to be the most appropriate, using guidelines which have been prepared by experts across the UK. The Children’s Cancer and Leukaemia Group (CCLG) is an important organisation which helps to produce these guidelines. Follow-up care Most children with ALL are cured. If the leukaemia recurs after initial treatment, it usually does so within the first three years. Further


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care Most children with ALL are cured. If the leukaemia recurs after initial treatment, it usually does so within the first three years. Further treatment can then be given. Long-term side effects (late side effects) are rare, and most children with ALL grow and develop normally. If you have specific concerns about your child’s condition and treatment, it’s best to discuss them with your child’s doctor, who knows the situation in detail. Your feelings As a parent, the fact that your child has cancer is one of the worst situations you can be faced with. You may have many emotions, such as fear, guilt, sadness, anger and uncertainty. These are all normal reactions and are part of the process that many parents go through at such a difficult time. Your child may have a variety of powerful emotions throughout their experience with cancer. Further information and advice if your child has cancer Source: Children's Cancer and Leukemia Group - Opens in new browser window Last updated: 09


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Further information and advice if your child has cancer Source: Children's Cancer and Leukemia Group - Opens in new browser window Last updated: 09 October 2024 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Other health sites Scottish Cancer Network: Cancer patient information Search for cancer support services near you Enter a place or postcode NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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https://www.nhsinform.scot/illnesses-and-conditions/cancer/cancer-types-in-teenagers-and-young-adults/acute-lymphoblastic-leukaemia-teenagers-and-young-adults/


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Acute lymphoblastic leukaemia | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Cancer Cancer types in teenagers and young adults Acute lymphoblastic leukaemia: Teenagers and young adults Acute lymphoblastic leukaemia: Teenagers and young adults Introduction Leukaemia, blood tests and bone marrow Tests for ALL Treating ALL Introduction This section is for teenagers and young adults and is about a type of cancer called acute lymphoblastic leukaemia (ALL). The other main type of leukaemia that can affect teenagers and young adults is acute myeloid leukaemia. If you’re looking for information about ALL in people of all ages, please see our general ALL section. Leukaemia is a cancer of the white blood cells. In leukaemia, the process for making new white blood cells gets out of control. Immature white blood cells (called blasts) keep being made and build


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In leukaemia, the process for making new white blood cells gets out of control. Immature white blood cells (called blasts) keep being made and build up in the bone marrow until there isn’t enough room for the bone marrow to make healthy white blood cells, red blood cells and platelets. The body needs these cells to: help fight infection (white cells) carry oxygen from the lungs around the body (red blood cells) stop cuts bleeding by clotting blood (platelets) Symptoms Many of the symptoms of ALL are caused by having fewer than normal healthy blood cells in the body. Symptoms can include: looking paler than usual and feeling tired – because of too few red blood cells (anaemia) bruises – you may bruise more easily and it could take longer for bleeding to stop, if you have less blood clotting cells (platelets) than normal infections – because there are too few mature white blood cells to fight infection aches and pains in your bones swollen glands (lymph nodes) in your neck, under your


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there are too few mature white blood cells to fight infection aches and pains in your bones swollen glands (lymph nodes) in your neck, under your arm or in your groin feeling unwell and run down fever and sweats – you may have a high temperature without any obvious cause, such as an infection headaches and visual disturbance There can be other reasons you may have these symptoms. But if you are worried that you may have ALL, you should speak to your GP. They’ll examine you and refer you to a hospital if they think you need to see a specialist doctor. Causes It’s not known exactly what causes ALL. Research is going on to try to find out. Young people with some genetic conditions, such as Down’s syndrome or Li-Fraumeni syndrome, are at an increased risk of developing ALL. A genetic condition is something you are born with. If you’re worried about ALL If you think you have some of the symptoms of ALL you should speak to your GP. They can talk to you about your symptoms and arrange any


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about ALL If you think you have some of the symptoms of ALL you should speak to your GP. They can talk to you about your symptoms and arrange any tests they think you might need. Leukaemia, blood tests and bone marrow To understand leukaemia, it can help to know a little about the blood and bone marrow. Leukaemia is a cancer of the white blood cells. All blood cells are made in the bone marrow, which is like a blood cell factory inside bones. A type of cell in the bone marrow, called a stem cell, can make any kind of blood cell your body needs. There are 3 main types of blood cells: white blood cells – which help fight infection red blood cells – which carry oxygen from the lungs around the body platelets – which clot blood to stop cuts bleeding The bone marrow normally makes millions of blood cells every day. To begin with, these new blood cells, called blasts, are not fully developed (they’re immature). The main job of blast cells is to make more blood cells like themselves. They


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blood cells, called blasts, are not fully developed (they’re immature). The main job of blast cells is to make more blood cells like themselves. They can’t do any of the jobs that mature blood cells can do, like carrying oxygen or fighting infection. Blast cells normally stay inside the bone marrow until they’ve matured into fully-developed blood cells. Once blood cells are mature, they’re ready to do their jobs. They leave the bone marrow and go into the bloodstream, where they can be carried to wherever they’re needed. How leukaemia develops In leukaemia, the process for making new white blood cells gets out of control and immature white blood cells (blasts) keep being made. They build up in the bone marrow until there isn’t enough room for the bone marrow to make healthy white cells, red cells and platelets. Types of leukaemia Leukaemia is a cancer of the white blood cells. Healthy white blood cells are made from two types of blood cells: lymphoblasts that make lymphocytes myeloid


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is a cancer of the white blood cells. Healthy white blood cells are made from two types of blood cells: lymphoblasts that make lymphocytes myeloid cells (myeloblasts) that make other types of white blood cells such as neutrophils Leukaemias are named after the type of white blood cell that has become abnormal and started growing out of control. The most common types in teenagers and young adults are AML and ALL: acute myeloid leukaemia (AML) is leukaemia that starts from abnormal myeloid cells acute lymphoblastic leukaemia (ALL) is leukaemia that starts from abnormal lymphoblasts There are other types of leukaemia that are more common in older people. We also have more information about: symptoms and causes of ALL having tests for ALL being treated for ALL If you’re looking for information about ALL in people of all ages, read our general ALL section. Tests for ALL It’s important to remember that the symptoms of ALL can be caused by lots of different things. But you should go to your


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ALL section. Tests for ALL It’s important to remember that the symptoms of ALL can be caused by lots of different things. But you should go to your GP if you’re worried. They can talk to you about your symptoms and arrange any tests they think you might need. Visiting your GP Your GP will examine you and arrange for you to have blood tests. There can be different reasons for your symptoms, so you’ll need a blood test to help diagnose acute lymphoblastic leukaemia (ALL). If you have ALL, a blood test will usually find leukaemia cells and you’ll be referred to a specialist at the hospital. This specialist is called a haematologist and is a doctor who treats people with blood problems. At the hospital The haematologist will examine you and ask you about your symptoms and any recent illnesses. They will also arrange for you to have some more tests. These may include: blood tests – you’ll need more blood tests even if you’ve had some already to look at the changes in the leukaemia cells


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tests. These may include: blood tests – you’ll need more blood tests even if you’ve had some already to look at the changes in the leukaemia cells and help the doctors decide on the best treatment for you bone marrow test – to count the numbers of leukaemia cells in the bone marrow and get samples for cytogenetic and immunophenotyping testing lumbar puncture – a small sample of the fluid that surrounds your brain and spinal cord is taken to check for leukaemia cells chest X-ray – this may also be done to see if there are any swollen lymph nodes (glands) in your chest If you have ALL, you might need a few more tests to check how your body is working in general. These could be blood tests, or an ultrasound scan of the tummy (abdomen) to look at your liver, spleen and kidneys, and an echocardiogram (an ultrasound of the heart). This may seem like a lot of tests, but they give the doctors important information that will help them give you the right treatment. Waiting for test results can


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like a lot of tests, but they give the doctors important information that will help them give you the right treatment. Waiting for test results can be a scary time, but understanding a little about them – what will happen, how you’ll feel and when you’ll get the results – can help you cope. Thinking about how you feel and getting support from family, friends or your specialist nurse and doctor can also make it a bit easier. You could also use the Macmillan Support Line to get information and advice. We also have more information about: symptoms of ALL being treated for ALL leukaemia, blood cells and bone marrow If you’re looking for information about ALL in people of all ages, read our general ALL section. Treating ALL The main treatment for acute lymphoblastic leukaemia (ALL) is chemotherapy. This means having anti-cancer drugs to destroy the leukaemia cells. You’ll also have drugs called steroids, which help the chemotherapy to work. The treatment for ALL is pretty intensive at


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the leukaemia cells. You’ll also have drugs called steroids, which help the chemotherapy to work. The treatment for ALL is pretty intensive at times and can cause unpleasant side effects. But you’ll be in close contact with the hospital when you’re most likely to feel unwell and the staff will be able to help if things get tough. Don’t feel you have to be brave. Be honest about how you are feeling with your doctors and nurses. They can give you medicines that can help you feel better. ALL is treated in 3 phases: getting rid of the leukaemia – remission induction keeping the leukaemia away – consolidation and delayed intensification therapy keeping the leukaemia away long-term – continuing or maintenance therapy You usually start chemotherapy pretty quickly after finding out that you have ALL. You’ll be in hospital for your treatment to begin with. If you’re 18 or younger, you’ll be treated in a specialist Principal Treatment Centre (PTC) for teenagers and young adults (TYA). If you’re


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with. If you’re 18 or younger, you’ll be treated in a specialist Principal Treatment Centre (PTC) for teenagers and young adults (TYA). If you’re 19 or older, you’ll be offered the choice of having treatment at the PTC or another hospital closer to home called a TYA designated hospital. You’ll be given chemotherapy as tablets, by injection and into your bloodstream (intravenously). You’ll also be given chemotherapy into the fluid around the spinal cord to make sure the leukaemia cells can’t hide there. This is called central nervous system (CNS) therapy. It’s also known as intrathecal therapy. You’ll have a ‘line’ put in to one of your main veins to make it easier for you to have intravenous treatment. Your nurses and doctors can also use the line to take blood samples for blood tests. There are different kinds of lines. Having chemotherapy can be hard. But the staff looking after you will give you medicines to help you cope with any side effects so you can stay strong enough to have


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can be hard. But the staff looking after you will give you medicines to help you cope with any side effects so you can stay strong enough to have treatment. And you’ll be given medicines to stop you feeling sick and antibiotics to help prevent infections. There will probably be times when you feel rough and other times when you’ll feel better. You might also feel upset, down or irritable. Talking to someone you trust can help you cope with these feelings. Being in hospital or coming up to hospital for clinics and treatment can be frustrating, especially when you miss out on stuff happening at school, college, university or work, or on things your friends are doing. You could try talking to your friends and family about this and see what they can do to help you. It can also help to talk to any new friends you’ve made who are going through similar experiences to you. We have more information about chemotherapy that has been written for people of all ages, not just teens and young


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similar experiences to you. We have more information about chemotherapy that has been written for people of all ages, not just teens and young adults. Getting rid of the leukaemia (remission induction) The first phase of your treatment is about getting rid of the leukaemia. You’ll be given chemotherapy to kill as many leukaemia cells as possible. Remission means there is no sign of leukaemia cells in your blood or bone marrow. This type of treatment involves: chemotherapy to kill the leukaemia cells (including CNS therapy) steroids to help the chemotherapy work drugs (allopurinol or rasburicase) to help protect your kidneys from problems that can happen when lots of leukaemia cells are destroyed at once another tablet (for example ranitidine or lansoprazole) to stop indigestion or ulcers You need to stay in hospital during this phase of your treatment so the doctors can check how things are going. Treatment to get you into remission takes about 5 weeks, sometimes a bit longer. Being


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your treatment so the doctors can check how things are going. Treatment to get you into remission takes about 5 weeks, sometimes a bit longer. Being in hospital that long can be really difficult at times. If you’re struggling to cope, try and talk to your friends, family, doctors and nurses. It’s important not to bottle up your feelings otherwise your might end up finding it hard to cope. Drugs you may be given include: vincristine asparaginase daunorubicin mercaptopurine methotrexate Side effects Different chemotherapy can cause different side effects. Central nervous system therapy Chemotherapy given as tablets or into the blood can reach most places in your body. But it isn’t good at getting into the brain or spinal cord (called the central nervous system or CNS). So you’ll be given treatment into the fluid that goes around the CNS to target any leukaemia cells that might be hiding there. This is called CNS therapy. CNS therapy is given during remission induction treatment (to get


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target any leukaemia cells that might be hiding there. This is called CNS therapy. CNS therapy is given during remission induction treatment (to get rid of the leukaemia) and continues right until the end of maintenance therapy. Chemotherapy is given into the fluid, called cerebrospinal fluid or CSF, around your spinal cord. Drug treatment given into the CSF is called intrathecal therapy. It’s a bit like having a lumbar puncture but with chemotherapy added. A doctor puts a needle into the space between 2 small bones (vertebrae) near the bottom of your spine. Then they inject chemotherapy into the CSF. The CSF will carry the chemotherapy around your CNS so it can reach any leukaemia cells that might be there. The chemotherapy drug used for CNS therapy is called methotrexate. Side effects Most people don’t have side effects after having intrathecal methotrexate. But occasionally it can cause headaches, dizziness, tiredness or blurry vision for a few hours. Rarely other side effects like


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methotrexate. But occasionally it can cause headaches, dizziness, tiredness or blurry vision for a few hours. Rarely other side effects like seizures (fits), weakness of your arms or legs and changes in how awake you are can happen. But these almost always go away completely and you can still have the intrathecal injections in the future. Keeping leukaemia away This treatment is called consolidation and delayed intensification therapy. When you’re in remission, it means the doctors can’t see any leukaemia cells in your blood or bone marrow samples when they check them under the microscope. But there may still be leukaemia cells hiding in your body, so you need further treatment to get rid of these cells. You’ll be given different types of chemotherapy drugs. This is so the leukaemia cells don’t have a chance to get used to them (which is called drug resistance). This phase of treatment takes about 5 to 6 months. Most of the treatment can be given as an outpatient but you might need to


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called drug resistance). This phase of treatment takes about 5 to 6 months. Most of the treatment can be given as an outpatient but you might need to stay in hospital for some parts of it. Drugs you may be given include: cyclophosphamide cytarabine (ara-C) mercaptopurine methotrexate vincristine asparaginase doxorubicin Side effects Chemotherapy does cause side effects. Keeping the leukaemia away long term (maintenance therapy) This treatment is given to prevent the leukaemia from returning (known as relapse). The chemotherapy is given in low doses. You have it as an outpatient so you can keep doing all your normal, everyday activities when you’re having maintenance therapy. Maintenance therapy is given in 12-week cycles. You’ll have: mercaptopurine tablets each day methotrexate tablets once a week steroid tablets for 5 days every 4 weeks vincristine chemotherapy every 4 weeks methotrexate chemotherapy into your cerebrospinal fluid (CSF) every 12 weeks At the moment, boys have just


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vincristine chemotherapy every 4 weeks methotrexate chemotherapy into your cerebrospinal fluid (CSF) every 12 weeks At the moment, boys have just over 3 years of maintenance therapy and girls have just over 2 years. This is because it takes a bit longer in boys to get rid of any remaining leukaemia cells. During this time, you’ll have regular check-ups – usually every week or two – to check if your drug doses need to be adjusted and to make sure you’re OK. Very often, things like blood tests can be done at your GP practice or at home by a district nurse. Ask your doctor or nurse about arranging this. Source: Macmillan - Opens in new browser window Last updated: 09 October 2024 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Other health


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health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Other health sites Scottish Cancer Network: Patient information Search for cancer support services near you Enter a place or postcode NHS inform About NHS inform Editorial policy Contact us Webchat Give feedback about NHS inform Info for Me tool Terms and conditions Privacy and cookies policy Freedom of information (FOI) Accessibility Other languages and formats © 2025 NHS 24 – v1.1.1.17852


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https://www.nhsinform.scot/illnesses-and-conditions/cancer/cancer-types-in-adults/acute-myeloid-leukaemia/


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Acute myeloid leukaemia | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Cancer Cancer types in adults Acute myeloid leukaemia Acute myeloid leukaemia About acute myeloid leukaemia Symptoms of acute myeloid leukaemia Causes of acute myeloid leukaemia Diagnosing acute myeloid leukaemia Treating acute myeloid leukaemia Complications of acute myeloid leukaemia About acute myeloid leukaemia Leukaemia is cancer of the white blood cells. Acute leukaemia means it progresses rapidly and aggressively, and usually requires immediate treatment. Acute leukaemia is classified according to the type of white blood cells affected. The 2 main types of white blood cells are: lymphocytes – mostly used to fight viral infections myeloid cells – which perform a number of different functions, such as fighting bacterial infections, defending the body against parasites and


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myeloid cells – which perform a number of different functions, such as fighting bacterial infections, defending the body against parasites and preventing the spread of tissue damage This topic focuses on acute myeloid leukaemia (AML), which is an aggressive cancer of the myeloid cells. The following types of leukaemia are covered separately: acute lymphoblastic leukaemia chronic myeloid leukaemia chronic lymphocytic leukaemia Signs and symptoms of AML The symptoms of AML usually develop over a few weeks and become increasingly more severe. Symptoms can include: pale skin tiredness breathlessness frequent infections unusual and frequent bleeding, such as bleeding gums or nosebleeds In more advanced cases, AML can make you extremely vulnerable to life-threatening infections or serious internal bleeding. Read more about the complications of AML Seeking medical advice You should see your GP if you or your child have possible symptoms of AML. Although it’s highly unlikely that leukaemia is


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AML Seeking medical advice You should see your GP if you or your child have possible symptoms of AML. Although it’s highly unlikely that leukaemia is the cause, these symptoms should be investigated. If your GP thinks you may have leukaemia, they’ll arrange blood tests to check your blood cell production. If the tests suggest there’s a problem, you’ll be urgently referred to a haematologist (a specialist in treating blood conditions) for further tests and any necessary treatment. Read more about diagnosing AML What causes AML? AML occurs when specialised cells called stem cells, which are found in the bone marrow (a spongy material inside the bones), produce too many immature white blood cells. These immature cells are known as blast cells. Blast cells don’t have the infection-fighting properties of healthy white blood cells, and producing too many can lead to a decrease in the number of red blood cells (which carry oxygen in the blood) and platelets (cells that help the blood to


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too many can lead to a decrease in the number of red blood cells (which carry oxygen in the blood) and platelets (cells that help the blood to clot). It’s not clear exactly why this happens and, in most cases, there’s no identifiable cause. However, a number of factors that can increase your risk of developing AML have been identified. These include: previous chemotherapy or radiotherapy exposure to very high levels of radiation (including previous radiotherapy treatment) exposure to benzene – a chemical used in manufacturing that’s also found in cigarette smoke having an underlying blood disorder or genetic disorder, such as Down’s syndrome Read more about the causes of AML Who’s affected AML is a rare type of cancer. The risk of developing AML increases with age. It’s most common in people over 65. How AML is treated AML is an aggressive type of cancer that can develop rapidly, so treatment usually needs to begin soon after a diagnosis is confirmed. Chemotherapy is the main


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aggressive type of cancer that can develop rapidly, so treatment usually needs to begin soon after a diagnosis is confirmed. Chemotherapy is the main treatment for AML. It’s used to kill as many leukaemia cells in your body as possible and reduce the risk of the condition coming back (relapsing). In some cases, intensive chemotherapy and radiotherapy may be needed, in combination with a bone marrow or stem cell transplant, to achieve a cure. Read more about treating AML Symptoms of acute myeloid leukaemia The symptoms of acute myeloid leukaemia (AML) usually develop over a few weeks, becoming more severe as the number of immature white blood cells (blast cells) in your blood increases. Symptoms of AML can include: pale skin tiredness breathlessness a high temperature (fever) excessive sweating weight loss frequent infections unusual and frequent bleeding, such as bleeding gums or nosebleeds easily bruised skin flat red or purple spots on the skin (petechiae) bone and joint pain a


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and frequent bleeding, such as bleeding gums or nosebleeds easily bruised skin flat red or purple spots on the skin (petechiae) bone and joint pain a feeling of fullness or discomfort in your tummy (abdomen), caused by swelling of the liver or spleen In rare cases of AML, the affected cells can spread into the central nervous system. This can cause symptoms such as headaches, fits (seizures), vomiting, blurred vision and dizziness. When to seek medical advice See your GP if you or your child have these symptoms. Although it’s highly unlikely that AML is the cause, these symptoms need to be investigated and treated promptly. Causes of acute myeloid leukaemia Acute myeloid leukaemia (AML) is caused by a DNA mutation in the stem cells in your bone marrow that produce red blood cells, platelets and infection-fighting white blood cells. The mutation causes the stem cells to produce many more white blood cells that are needed. The white blood cells produced are still immature, so they don’t


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causes the stem cells to produce many more white blood cells that are needed. The white blood cells produced are still immature, so they don’t have the infection-fighting properties of fully developed white blood cells. These immature cells are known as ‘blast cells’. As the number of immature cells increases, the amount of healthy red blood cells and platelets decrease, and it’s this fall that causes many of the symptoms of leukaemia. Increased risk It’s not known what triggers the genetic mutation in AML, although a number of different factors that can increase your risk of developing the condition have been identified. The main risk factors for AML are outlined below. Radiation exposure Being exposed to a significant level of radiation can increase your chances of developing AML, although this usually requires exposure at very high levels. For example, rates of AML are higher in people who survived the atomic bomb explosions in Japan in 1945. In the UK, most people are unlikely to


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For example, rates of AML are higher in people who survived the atomic bomb explosions in Japan in 1945. In the UK, most people are unlikely to be exposed to levels of radiation high enough to cause AML. However, some people who have had radiotherapy as part of their treatment for previous cancer (see below) can be the exception. Benzene and smoking Exposure to the chemical benzene is a known risk factor for AML in adults. Benzene is found in petrol, and it’s also used in the rubber industry, although there are strict controls to protect people from prolonged exposure. Benzene is also found in cigarette smoke, which could explain why people who smoke have an increased risk of developing AML. Previous cancer treatment Treatment with radiotherapy and certain chemotherapy medications for an earlier, unrelated cancer can increase your risk of developing AML many years later. Leukaemia that develops as a result of previous cancer treatment is called ‘secondary leukaemia’ or


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your risk of developing AML many years later. Leukaemia that develops as a result of previous cancer treatment is called ‘secondary leukaemia’ or ‘treatment-related leukaemia’. Blood disorders People with certain blood disorders – such as myelodysplasia, myelofibrosis or polycythaemia vera (PCV) – have an increased risk of developing AML. Genetic disorders People with certain genetic disorders, including Down’s syndrome and Fanconi’s anaemia, have an increased risk of developing leukaemia. Other suggested triggers A number of other environmental factors that could trigger AML have also been suggested, including childhood vaccinations and living near a nuclear power station or a high-voltage power line. However, there’s no clear evidence to suggest that these can increase your risk of developing AML. Diagnosing acute myeloid leukaemia In the initial stages of diagnosing acute myeloid leukaemia (AML), your GP will check for physical signs of the condition and arrange for you to have


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In the initial stages of diagnosing acute myeloid leukaemia (AML), your GP will check for physical signs of the condition and arrange for you to have blood tests. A high number of abnormal white blood cells, or a very low blood count in the test sample, could indicate the presence of leukaemia. If this is the case, you’ll be urgently referred to a haematologist (a specialist in treating blood conditions). A haematologist may carry out further blood tests, in addition to some of the tests outlined on this page. Bone marrow biopsy To confirm a diagnosis of AML, the haematologist will take a small sample of your bone marrow to examine under a microscope. This procedure is known as a bone marrow biopsy, which is usually carried out under a local anaesthetic. The haematologist will numb an area of skin at the back of your hip bone, before using a thin needle to remove a sample of liquid bone marrow. In some cases, a larger needle may also be used to remove a small amount of bone and bone


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a thin needle to remove a sample of liquid bone marrow. In some cases, a larger needle may also be used to remove a small amount of bone and bone marrow together. You won’t feel any pain during the procedure, but you may experience some bruising and discomfort for a few days afterwards. The procedure takes around 15 minutes to complete, and you shouldn’t have to stay in hospital overnight. The bone marrow sample will be checked for cancerous cells. If cancerous cells are present, the biopsy can also be used to determine the type of leukaemia you have. Further tests Additional tests can be used to reveal more information about the progress and extent of your AML. They can also provide insight into how the condition should be treated. These tests are described below. Genetic testing Genetic tests can be carried out on blood and bone marrow samples to identify the genetic makeup of the cancerous cells. There are many specific genetic variations that can occur in AML, and knowing the


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samples to identify the genetic makeup of the cancerous cells. There are many specific genetic variations that can occur in AML, and knowing the exact type of AML you have can help doctors make decisions about the most appropriate treatment. For example, people who have a type of AML known as acute promyelocytic leukaemia (APML) are known to respond well to a medicine called All Trans-Retinoic Acid (ATRA). Scans If you have AML, a computerised tomography (CT) scan, X-ray or echocardiogram (an ultrasound scan of the heart) may be used to check that your organs, such as your heart and lungs, are healthy. These tests are carried out because it’s important for doctors to assess your general health before they can decide on the most appropriate treatment for you. Lumbar puncture In rare situations where it’s thought there’s a risk that AML has spread to your nervous system, a lumbar puncture may be carried out. In this procedure, a needle is used to extract a sample of cerebrospinal fluid


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spread to your nervous system, a lumbar puncture may be carried out. In this procedure, a needle is used to extract a sample of cerebrospinal fluid (which surrounds and protects your spine) from your back, so it can be checked for cancerous cells. If cancerous cells are found in your nervous system, you may need to have injections of chemotherapy medication directly into your cerebrospinal fluid as part of your treatment. Treating acute myeloid leukaemia Acute myeloid leukaemia (AML) is an aggressive condition that develops rapidly, so treatment will usually begin a few days after a diagnosis has been confirmed. As AML is a complex condition, it’s usually treated by a multidisciplinary team (MDT) – a group of different specialists working together. Your treatment plan Treatment for AML is often carried out in 2 stages: induction – the aim of this initial stage of treatment is to kill as many leukaemia cells in your blood and bone marrow as possible, restore your blood to proper


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the aim of this initial stage of treatment is to kill as many leukaemia cells in your blood and bone marrow as possible, restore your blood to proper working order and treat any symptoms you may have consolidation – this stage aims to prevent the cancer returning (relapsing), by killing any remaining leukaemia cells that may be present in your body The induction stage of treatment isn’t always successful and sometimes needs to be repeated before consolidation can begin. If you have a relapse after treatment, both re-induction and consolidation may need to be carried out. This may be the same as your first treatment, although it’s likely to involve different medications or a stem cell transplant. If you’re thought to have a high risk of experiencing complications of AML treatment – for example, if you’re over 75 years of age or have another underlying health condition – less intensive chemotherapy treatment may be carried out. This is less likely to successfully kill all of the


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another underlying health condition – less intensive chemotherapy treatment may be carried out. This is less likely to successfully kill all of the cancerous cells in your body, but it can help control your condition. Induction The initial treatment you have for AML will largely depend on whether you’re fit enough to have intensive chemotherapy, or whether treatment at a lower dosage is recommended. Intensive chemotherapy If you can have intensive induction chemotherapy, you’ll usually be given a combination of chemotherapy medication at a high dose to kill the cancerous cells in your blood and bone marrow. This stage of treatment will be carried out in hospital or in a specialist centre, as you’ll need very close medical and nursing supervision. You’ll have regular blood transfusions because your blood won’t contain enough healthy blood cells. You’ll also be vulnerable to infection, so it’s important that you’re in a clean and stable environment where your health can be carefully


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cells. You’ll also be vulnerable to infection, so it’s important that you’re in a clean and stable environment where your health can be carefully monitored and any infection you have can be promptly treated. You may also be prescribed antibiotics to help prevent further infection. Depending on how well you respond to treatment, the induction phase can last from four weeks to a couple of months. You may be able to leave hospital and receive treatment on an outpatient basis if your symptoms improve. For intensive treatment, the chemotherapy medications will be injected into a thin tube that’s inserted either into a blood vessel near your heart (central line) or into your arm (a peripherally inserted central catheter, or PICC). In very rare cases, chemotherapy medication may also be directly administered into your cerebrospinal fluid to kill any leukaemia cells that may have spread to your nervous system. This is done using a needle that’s placed into your spine, in a similar way to a


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any leukaemia cells that may have spread to your nervous system. This is done using a needle that’s placed into your spine, in a similar way to a lumbar puncture. Side effects of intensive chemotherapy for AML are common. They can include: nausea vomiting diarrhoea loss of appetite sore mouth and mouth ulcers (mucositis) tiredness skin rashes hair loss infertility – which may be temporary or permanent (see complications of AML for more information) Most side effects should resolve once treatment has finished. Tell a member of your care team if side effects become particularly troublesome, as there are medicines that can help you cope better with certain side effects. Read more about the side effects of chemotherapy Non-intensive chemotherapy If your doctors don’t think you’re fit enough to withstand the effects of intensive chemotherapy, they may recommend non-intensive treatment. This involves using an alternative type of chemotherapy to the standard intensive therapy, which is


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they may recommend non-intensive treatment. This involves using an alternative type of chemotherapy to the standard intensive therapy, which is designed more to control leukaemia rather than cure it. The main aim of this treatment is to control the level of cancerous cells in your body and limit any symptoms you have, while reducing your risk of experiencing significant side effects of treatment. The medications used during non-intensive chemotherapy may be given through a drip into a vein, by mouth or by injection under the skin, and can often be given on an outpatient basis. All Trans-Retinoic Acid (ATRA) If you have the sub-type of AML known as acute promyelocytic leukaemia, you’ll usually be given capsules of a medicine called ATRA, in addition to chemotherapy. ATRA works by changing the immature white blood cells (blast cells) into mature healthy cells, and can reduce symptoms very quickly. Side effects of ATRA can include headaches, nausea, bone pain, and dry mouth, skin and


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mature healthy cells, and can reduce symptoms very quickly. Side effects of ATRA can include headaches, nausea, bone pain, and dry mouth, skin and eyes. Consolidation If induction is successful, the next stage of treatment will be consolidation. This often involves receiving regular injections of chemotherapy medication that are usually given on an outpatient basis, which means that you won’t have to stay in hospital overnight. However, you may need some short stays in hospital if your symptoms suddenly get worse or if you develop an infection. The consolidation phase of treatment lasts several months. Other treatments Many other treatments are used for AML. Radiotherapy Radiotherapy involves using high doses of controlled radiation to kill cancerous cells. There are 2 main reasons why radiotherapy is usually used to treat AML: to prepare the body for a bone marrow or stem cell transplant to treat advanced cases that have spread to the nervous system and/or brain, although this is


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the body for a bone marrow or stem cell transplant to treat advanced cases that have spread to the nervous system and/or brain, although this is uncommon Side effects of radiotherapy can include hair loss, nausea and fatigue. The side effects should pass once your course of radiotherapy has been completed. Bone marrow and stem cell transplants If chemotherapy doesn’t work, a possible alternative treatment option is a bone marrow or stem cell transplant. Before transplantation can take place, the person receiving the transplant will need to have intensive high-dose chemotherapy and possibly radiotherapy to destroy the cells in their bone marrow. The donated stem cells are given through a tube into a blood vessel, in a similar way to chemotherapy medication. This process can put an enormous amount of strain on the body and cause significant side effects and potential complications, so you’ll usually need to stay in hospital for a few weeks. Transplantations have better outcomes if the


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side effects and potential complications, so you’ll usually need to stay in hospital for a few weeks. Transplantations have better outcomes if the donor has the same tissue type as the person receiving the donation. The best candidate to provide a donation is usually a brother or sister with the same tissue type. Transplantations are most successful when they’re carried out on children and young people, or older people who are otherwise in good health, and when there’s a suitable donor, such as a brother or sister. Read about bone marrow donation Azacitidine Azacitidine is a possible alternative treatment for adults with AML who can’t have a stem cell transplant. It’s recommended by the National Institute for Health and Care Excellence (NICE) for use in certain circumstances – for example, depending on the characteristics of the person’s blood and bone marrow. Azacitidine is a chemotherapy medication that’s given by injection under the skin. It interferes with the growth of cancer


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blood and bone marrow. Azacitidine is a chemotherapy medication that’s given by injection under the skin. It interferes with the growth of cancer cells and destroys them, and also helps bone marrow to produce normal blood cells. NICE has more information about azacitidine for the treatment of AML Clinical trials and newer unlicensed treatments In the UK, a number of clinical trials are currently underway that aim to find the best way of treating AML. Clinical trials are studies that use new and experimental techniques to see how well they work in treating, and possibly curing, AML. As part of your treatment, your care team may suggest taking part in a clinical trial to help researchers learn more about the best way to treat your AML, and AML in general. If you take part in a clinical trial, you may be offered medication that isn’t licensed for use in the UK and isn’t normally available. However, there’s no guarantee that the techniques being studied in the clinical trial will work


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for use in the UK and isn’t normally available. However, there’s no guarantee that the techniques being studied in the clinical trial will work better than current treatments. Your care team can tell you whether there are any clinical trials available in your area, and can explain the benefits and risks involved. Complications of acute myeloid leukaemia If you have acute myeloid leukaemia (AML), you may experience a number of complications. These can be caused by the condition itself, although they can also occur as a side effect of treatment. Weakened immune system Having a weakened immune system – being immunocompromised – is a common complication of AML. Even if your blood is restored to normal working order with treatment, many of the medications that are used to treat AML can temporarily weaken your immune system. This means you’re more vulnerable to developing an infection, and any infection you develop could be more serious than usual. Complications arising from infection are


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more vulnerable to developing an infection, and any infection you develop could be more serious than usual. Complications arising from infection are the leading cause of death in people with AML. However, if treated early, nearly all infections respond to appropriate treatment. Therefore, you may be advised to: take regular doses of antibiotics to prevent bacterial infections maintain good personal and dental hygiene avoid contact with anyone who’s known to have an infection – even if it’s a type of infection that you were previously immune to, such as chickenpox or measles check with your GP to ensure that all of your vaccinations are up to date, although you won’t be able to have any vaccine that contains ‘live’ viruses or bacteria, such as the shingles vaccine and MMR vaccine (against measles, mumps and rubella) Report any possible symptoms of an infection to your treatment unit immediately because prompt treatment may be needed to prevent complications. Symptoms of an infection


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symptoms of an infection to your treatment unit immediately because prompt treatment may be needed to prevent complications. Symptoms of an infection can include: a high temperature (fever) a headache aching muscles diarrhoea tiredness Bleeding If you have AML, you’ll bleed and bruise more easily due to the low levels of platelets (clot-forming cells) in your blood. Bleeding may also be excessive. People with advanced AML are more vulnerable to excessive bleeding inside their body, which is the second most common cause of death in people with the condition. Serious bleeding can occur: inside the skull (intracranial haemorrhage) – causing symptoms such as a severe headache, stiff neck, vomiting and confusion inside the lungs (pulmonary haemorrhage) – causing symptoms such as coughing up blood, breathing difficulties and a bluish skin tone (cyanosis) inside the stomach (gastrointestinal haemorrhage) – causing symptoms such as vomiting blood and passing stools (faeces) that are very dark


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(cyanosis) inside the stomach (gastrointestinal haemorrhage) – causing symptoms such as vomiting blood and passing stools (faeces) that are very dark or tar-like in colour All these types of haemorrhage should be regarded as medical emergencies. Dial 999 immediately and ask for an ambulance if you think a haemorrhage is occurring. Infertility Many of the treatments that are used to treat AML can cause infertility. This is often temporary, but in some cases can be permanent. People who are particularly at risk of permanent infertility, are those who have received high doses of chemotherapy and radiotherapy in preparation for a bone marrow or stem cell transplant. Your treatment team can give a good estimation of the risk of infertility in your specific circumstances. It may be possible to guard against any risk of infertility before you begin your treatment. For example, men can have their sperm samples stored. Similarly, women can have eggs or fertilised embryos stored, which can then


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your treatment. For example, men can have their sperm samples stored. Similarly, women can have eggs or fertilised embryos stored, which can then be placed back into their womb, following treatment. However, as AML is an aggressive condition that develops rapidly, there may not always be time to do this before treatment needs to start. Source: NHS 24 - Opens in new browser window Last updated: 14 October 2024 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Don’t include personal information e.g. name, location or any personal health conditions. Email Address e.g. you@example.com Message Maximum of 500 characters Send feedback Add this page to Info For Me Also on NHS inform Acute lymphoblastic leukaemia Other health sites Anthony Nolan Blood Cancer UK: Acute myeloid leukaemia (ALM) Scottish Cancer Network: Patient information Search for cancer support services near you Enter a place or postcode NHS inform About NHS inform Editorial


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Acute myeloid leukaemia: Children | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotland’s Service Directory 0 Home Illnesses and conditions Cancer Cancer types in children Acute myeloid leukaemia: Children Acute myeloid leukaemia: Children Acute myeloid leukaemia (AML) is a type of blood cancer. A third of all childhood cancers are leukaemia. Less than a quarter of these are acute myeloid leukaemia (AML). AML can affect children of any age. Girls and boys are equally affected More children than ever are surviving childhood cancer. There are new and better drugs and treatments, and we can now also work to reduce the after-effects of having had cancer in the past. It’s devastating to hear that your child has cancer. At times it can feel overwhelming but there are many healthcare professionals and support organisations to help you through this difficult time. Understanding more about the cancer your child


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are many healthcare professionals and support organisations to help you through this difficult time. Understanding more about the cancer your child has and the treatments that may be used can often help parents to cope. Your child’s specialist will give you more detailed information and if you have any questions it’s important to ask the specialist doctor or nurse who knows your child’s individual situation. Leukaemia Leukaemia is a cancer of the white blood cells. All blood cells are produced in the bone marrow, the spongy substance at the core of some of the bones in the body. Bone marrow contains: red blood cells, which carry oxygen around the body platelets, which help the blood to clot and control bleeding white blood cells, which help to fight infection There are 2 different types of white blood cells: lymphocytes and myeloid cells (including neutrophils). These white blood cells work together to fight infection. Normally, white blood cells develop, repair and reproduce


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cells (including neutrophils). These white blood cells work together to fight infection. Normally, white blood cells develop, repair and reproduce themselves in an orderly and controlled way. In leukaemia, however, the process gets out of control and the cells continue to divide in the bone marrow, but do not mature. These immature dividing cells fill up the bone marrow and stop it from making healthy blood cells. As the leukaemia cells are not mature, they cannot work properly. This leads to an increased risk of infection. There are 4 main types of leukaemia: acute lymphoblastic (ALL) acute myeloid (AML) chronic lymphocytic (CLL) chronic myeloid (CML) Chronic leukaemias occur mostly in adults. CLL is exclusively an adult condition, whereas CML does occur rarely in children and young people. Each type of leukaemia has its own characteristics and treatment. This page is about acute myeloid leukaemia (AML). Acute myeloid leukaemia (AML) Acute myeloid leukaemia is an overproduction of


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and treatment. This page is about acute myeloid leukaemia (AML). Acute myeloid leukaemia (AML) Acute myeloid leukaemia is an overproduction of immature myeloid white blood cells (blast cells). Cells that have started to show some of the features of myeloid cells are said to show differentiation. Cells that do not show signs of becoming a particular type of white blood cell are known as undifferentiated. There are different sub-types of AML, depending on exactly which type of cell has become leukaemic, the stage of development (maturation) the cells are at, and whether the cells are differentiated. Knowing the sub-type of AML is important, as it helps doctors decide on the best treatment. There are several classification systems for the sub-types of AML. The most commonly used system in the UK is the French-American-British (FAB) system. FAB classification of AML M0 – AML with minimal evidence of myeloid differentiation M1 – AML without maturation M2 – AML with maturation M3 – Acute


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FAB classification of AML M0 – AML with minimal evidence of myeloid differentiation M1 – AML without maturation M2 – AML with maturation M3 – Acute promyelocytic leukaemia (APL) M4 – Acute myelomonocytic leukaemia M5 – Acute monocytic/monoblastic leukaemia M6 – Acute erythroleukaemia M7 – Acute megakaryoblastic leukaemia A newer system known as the WHO (World Health Organization) classification system is also sometimes used. Causes The exact cause of AML is unknown. Research into possible causes of this disease is ongoing. Children with certain genetic disorders, such as Down’s syndrome or Li-Fraumeni syndrome, are known to have a higher risk of developing leukaemia. Brothers and sisters of a child with AML have a slightly increased risk of developing it, although this risk is still small. Other non-cancerous conditions, such as aplastic anaemia or the myelodysplastic syndromes (MDS), may increase a child’s risk of developing AML. AML, like all types of cancer, is not infectious and


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anaemia or the myelodysplastic syndromes (MDS), may increase a child’s risk of developing AML. AML, like all types of cancer, is not infectious and cannot be passed on to other people. Signs and symptoms As the leukaemia cells multiply in the bone marrow, the production of normal blood cells is reduced. Children may therefore become tired and lethargic because of anaemia, which is caused by a lack of red blood cells. Children may develop bruises, and bleeding may take longer to stop because of the low number of platelets present in their blood. Sometimes they may suffer from infections because of low numbers of normal white blood cells. A child is likely to feel generally unwell and may complain of aches and pains in the limbs or may have swollen lymph glands. At first, the symptoms are just like those of a viral infection, but when they continue for more than a week or two, the diagnosis usually becomes clear. How AML is diagnosed A blood test usually shows low numbers of normal


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they continue for more than a week or two, the diagnosis usually becomes clear. How AML is diagnosed A blood test usually shows low numbers of normal white blood cells and the presence of abnormal leukaemia cells. A sample of bone marrow is needed to confirm the diagnosis. The bone marrow sample is also examined to check for any abnormalities in the chromosomes of the leukaemia cells. A test called a lumbar puncture is done to see if the spinal fluid contains any leukaemia cells. A chest X-ray is also done, which will show if there are any enlarged glands in the chest. Other tests may be necessary, depending on your child’s symptoms. These tests will help to identify the precise type of leukaemia, and help doctors to decide on the best treatment. Treatment The aim of treatment for AML is to destroy the leukaemia cells and enable the bone marrow to work normally again. Chemotherapy is the main treatment for AML. Usually a combination of chemotherapy drugs is given, according to a


