Ventricular Septal Defect (VSD)

VSD is the most common congenital anomaly of the heart and it accounts for 15-25% of congenital heart disease. This is described as a "hole in the heart". The heart is made of 4 chambers the right and left atrium on top of the right and left ventricles. Unoxygenated blood comes from all the body and is channeled into the right atrium this then goes to the right ventricle and this gets oxygenated through the lungs then passes the left atrium to the left ventricle and this becomes oxygenated blood that gets distributed through the aorta to the rest of the body. The VSD is basically a hole in between the chambers of the ventricles that result in mixing of the oxygenated and unoxygenated blood.

Usually for the first few weeks of life a heart murmur can be heard by your doctor and most of the babies will be asymptomatic especially when the VSD is small. In some cases when the VSD is moderate or large the babies will not be gaining enough weight. They will be breathing faster than usual and sometimes their color looks dusky from time to time.

Treatment:
Small VSD usually close over time. This will be followed-up by the baby's cardiologist Moderate to large VSDs might need surgical intervention but they do not do the surgery till the baby is about 6 months of age. They want the baby to be gaining enough weight by giving them a high caloric diet at 24 to 26 kcal per ounce and putting some feeding tube to help them gain weight.They also start them on some diuretics or heart medicine to help maintain them and try to control their symptoms.

The great thing about this ventricular septal defects is that most of them resolve on its own and it is easily correctable by surgery.

What is Bell's Palsy?

The chief complaint that you would hear most of the time would be "one side of my child's face does not seem to be moving, this is more noticeable when he cries, laughs or screams". The child will be unable to close the eye on the affected side and the corner of the mouth will droop. This is considered a common disorder in infancy to adolescence. Taste on the front of the tongue might be lost but there should be no numbness to the area. The most important thing you want to prevent is dryness of the affected are which will result in keratitis. Your doctor will prescribe some eye drops to prevent this from happening. The facial nerve on the affected side is considered to be swollen thus this symptoms appear.

The most common reason for this palsy is that the child had some type of viral infection approximately 2 weeks prior to the event. Most common cause is the Epstein-Barr virus, Lyme disease (you usually see this in the Northeast area), herpesvirus and mumps virus. This has excellent prognosis because 85% will resolve completely without residuals, 10% with very mild residual weakness and only 5% are left with severe facial weakness.

Steroids do not induce remission and is not recommended but since the pathophysiology is swelling of the facial nerve some people think that this might help a little bit. If palsy seems to be chronic or persistent you need to consider other facial nerve tumors that can impinge on the nerve to present with the symptoms. Physical therapy might help a little bit in the recovery process.

Measles

Koplik's Spot

Measles Rash

Measles remains the most common disease in other parts of the world and this is the leading cause of vaccine preventable deaths among young children. There has been pockets of epidemics in Europe and South Africa in the last year according to the Centers for Disease Control and Prevention. Immigration can not be avoided and exposure to the measles virus is inevitable in the United States. The problem is with the scare that "MMR is linked to autism" there are a number of families who refuse to vaccinate their children and it will only be time before we see this spread all over the country. Since most physicians have not seen measles for a long time they may not be familiar with how it presents.

Signs and Symptoms

• fever

• runny nose


• cough


• watery eyes/conjunctivitis


• erythematous maculopapular rash

• Koplik's spot (rash noticed in the inner cheek area)

Complications

• croup
• ear infections
• pneumonia
• diarrhea
• encephalitis (Infection of the brain)
• subacute sclerosing panencephalitis (SSPE) a rare degenerative central nervous disease characterized by behavioral and intellectual deterioration and seizures
  

The only natural hosts of the measles are humans and is transmitted by direct contact with infectious oral droplets. Incubation period is from 8 to 12 days from exposure to onset of symptoms. There is a specific antibody test for measles IgM antibody to test for the infection.

Treatment

There is no specific treatment for measles, it is mostly symptomatic . The vaccine is most most effective in preventing this from occurring.

Resource: cdc.gov and the redbook

What to do with my Biting Toddler?

Biting behavior in toddlers is a developmental response to frustration and anger. Remember that the communication skills at this age is very limited and they do not know how to respond to their environment. Toddlers who bite do not do this purposefully or maliciously. You can not assume that the child is willfully misbehaving. If you know that this is a developmental response we can intervene and teach him the right way to react to what he feels.

• Do not bite him back because this is sending him a wrong message that biting is okay and he will be repeating it again.
• Watch and re-direct - if he is at home and you are in the vicinity you can pretty much predict when he starts getting upset and will start to bite, try to re-direct his attention by showing him a different activity or a different toy, try to distract him. You can instruct the people at the daycare to do the same thing.
• Teach - when a biting episode happens look into his eye sternly and talk in short sentences "biting is not good", "do not bite". Long winding explanations do not work with toddlers the meaning will be lost after a few seconds. Try to go and console the victim and make sure to let him go close to the victim to show him what he has done to cause harm.
• Avoid playful biting - this can send mixed signals to the toddler that it is alright to bite
• Time outs - If biting becomes worse we need to result to timeouts. One minute for each year of age. You look into their eyes and tell them in short sentences what they did wrong and go to the time out chair. This may take awhile before they understand it. Do not do this longer than the recommended time because if they stay there longer they might forget what was the reason they were put in timeout in the first place.
• Change Day cares - you can try to look for a daycare with smaller class sizes, sometimes toddlers get frustrated when they do not get the attention so they will try to do things to get it whether it is good or bad.

First Aid for Bites:

• after a bite wash the area very well with soap and water
• call your pediatrician if there is a break in the skin because this might warrant prophylactic antibiotics, the mouth has a lot of bacteria which might result in infection

New Car Seat Recommendations

The newest recommendation by the American Academy of Pediatrics is that the infant needs to be rear-facing in a car seat till they turn 2 years of age. Multiple studies have shown that infants survive the accident better with less injuries facing backwards than forwards.

• birth to 2 years of age up to 35 lbs rear-facing

(get a rear-facing convertible seat for children up to 35 pounds)

• over 2 year of age forward facing car-seat with a harness
• under 4 feet 9 inches tall booster seat
• over 4 feet 9 inches tall-safety belt in the back seat
• All children under the age of 13 years old should ride in the back seat

What is the Arizona law?

The Arizona Child Passenger Restraint Law says that children under 5 years of age need to be in a child passenger restraint device when in a moving vehicle.

As you can see what is lawful in Arizona may not be safe for the children. Children older than 5 years of age and under 4 feet 9 inches still needs to be in a booster seat.

Hepatitis C

This is a virus that is indistinguishable from the signs and symptoms of Hepatitis A and B. The only way to differentiate this is to obtain a blood work for the hepatitis panel.

Signs and Symptoms:

• fever
• malaise
• anorexia
• nausea
• vomiting
• jaundice
• hepatitis
• asymptomatic

They noticed that jaundice secondary to Hepatitis C occurs less than 20% of the time and abnormalities in liver function is less pronounced as compared to Hepatitis B. Persistent infection in children occur 50-60% of the time but most children are asymptomatic. Studies on therapy has been limited and the available mode of treatment is only effective half of the time. With advancing age people who have chronic hepatitis C infection are a a risk of developing chronic hepatitis and possible cirrhosis or hepatocellular carcinoma. Children with chronic infection should be screened periodically.

There is a 5% chance an infant of an infected mother would acquire the infection. The anti-HCV test should not be performed until after 18 months of age because it might result in a false positive because of passive maternal antibody which is present in their bloodstream.

Resource: The Redbook by the American Academy of Pediatrics

What is Intussusception?

This is the most common cause of intestinal obstruction from 3 months of age to 6 years old. This usually involves the lower gastrointestinal tract resulting in a telescoping of the more proximal part into the distal portion of the gut. There is a male to female predominance as 4:1. As a pediatrician this is one of the differential diagnosis we think of once babies are inconsolable .

Signs and Symptoms:

• sudden onset of severe paroxysmal colicky pain
• infant looks normal in between episodes
• this can be accompanied by straining and loud cries
• if this is not reduced the infant will become progressively weak and lethargic
• vomiting may occur early in the course
• blood may start passing within the first 12 hours which is called the currant jelly stool because mucous and blood are intermixed together, but this might not occur in 1-2 days in some cases

Diagnosis:

The history and physical is usually sufficient to diagnose this entity. Plain abdominal x-ray maybe warranted to show signs of obstruction. Barium enema will show a filling defect resulting from the obstruction.

Differential Diagnosis:

It is particularly difficult to sometimes differentiate this from gastroenteritis. Meckel's diverticulm is usually painless with bloody stools. The bloody stools from Henoch-Schonlein Purpura usually have joint pains.

Treatment:

This is considered an emergency procedure once diagnosis is certain and if there are no signs of shock or dehydration reduction by using an air enema is thetreatment of choice if not exploratory laparotomy with manual reduction by the surgeon is indicated.