Thursday, September 23, 2010

8.38 Child Medical care/Pediatric Self Help

Physician's Notebooks 8 - See Homepage -
38. Pediatric Self-Help - Update 09 April 2018

Infant & Child Eye Abnormalities: Left and right eyes slightly externally misaligned (looking away from each other) is seen in newborns, sometimes normally, and if normal will correct by about 3 months. Misalignments more than 15 degrees are abnormal. These are either external or internal (cross-eye). The cross eyed condition is discovered early, initially intermittent and then persistent. Typically, the cross-eye is caused by severe farsightedness that forces the child excessively to cross its eyes to see clearly close up. Treatment with corrective lenses usually leads to realignment of the eyes and it becomes permanent after 6 months use of the glasses. In contrast, persistent external deviation of both eyes may be due to mental retardation (although it can be found in mentally normal kids). It may not be noted until later in childhood and should always get a complete neurological check for developmental delay of the brain.
   It is important that any eye misalignment be evaluated by age 6 months because failure to diagnose and treat it could lead to lifetime blindness in one eye.

Well-Child Watching: You as parent must use experience, common sense, and pediatric reading in deciding when medical intervention is called for. You should have faith in a child’s natural power to resist disease. A properly self-educated parent can make fewer mistakes and that is where your reading Notebooks will help. A little time is important to minimize misjudgment. For example, a cramp which at seemed the usual upset stomach, by has shifted to pain in right lower abdomen of appendicitis.
Sending a child to school, who has even a slightest suspicion of illness, puts him out of your observation for what may be the crucial several hours between the questionable and the obvious.
   Serious illness in a child is preceded by appetite loss, and a red flasher ought to go off if your child does not finish his cereal or leaves the usually gulped-down glass of milk half empty. A second sign is irritability, which may show in unusual quietness or in crying in infant. Excess drowsiness too. These may be used in a negative sense in that a child who downs breakfast with gusto and who shows energy and good mood is almost certainly not going to get ill later that day.
   Children get sudden high fever easier than adults; with flu-like illness a child’s temperature will spike to 40C (104F). This is a good sign since it indicates strong immune response. Bacteria and virus are killed or inactivated by high temperature. Such fever, as “spike” implies, is brief. Childhood fever is best lowered by acetaminophen/Tylenol. Do not use aspirin or other NSAID for fever in children because of risk of Reye syndrome. With acute fever and no other sign, inspect skin for rash, which will often develop after fever spike. (A few acute viral infections in children have a rash that precedes the fever)
   When looking for a skin rash, take off all the child’s clothes and inspect in good light. Rash is most prominent on face, front of torso and arm; it may be distinctive like the red-rimmed small blisters of chickenpox, the slapped-face like reddening of scarlet fever, the small red elevations of measles. Some rashes announce by location, such as rubella behind ears. Nelson’s Pediatrics has color photos of typical childhood rashes. In mouth on inner side of cheek look with flashlight for an enanthem (inside-mouth, inner cheek rash).
   Ask child to open mouth wide and using flashlight look at throat while he is saying a prolonged “Ahhh”. Beefy red throat with enlarged tonsils coming out from the sides is typical of pharyngitis with tonsillitis. Usually the child will admit to sore throat. Look also for white spots on tonsils, signifying either a beta hemolytic strep bacteria infection or, more often, a virus. When tonsillitis is discovered with fever, a visit to pediatric clinic to do a throat-swab culture for diagnosis and to get antibiotic is wise. 
   Next have the child lie down flat with no pillow, ask him or her to relax abdomen while letting out a deep breath, and press heel of your hand slowly into right lower part of his abdomen. If he complains of pain on palpation, remove your palpating hand suddenly and note if he complains more. If right lower pain is found, appendicitis should be suspected and an emergency room consulted. Key area of McBurney’s point that shows appendicitis is located 2/3 on a line from navel to right pelvic iliac bone crest but any tenderness in abdomen needs immediate physician visit.
   Look at the child’s urine for the deep amber color that precedes jaundice of hepatitis. If you have Dipstick, also test the urine.
   A useful play-training that parent ought to promote is the Doctor Exam Game. From earliest age make this into a pleasant interaction in which you healthily reward good cooperation with hug, cuddle and other show of affection (For opening mouth wide, for sitting still during ear exam, for allowing examiner to palpate abdomen and relaxing it during exam, for taking own temp with oral thermometer and for learning to read it). Resourceful parent, starting from infancy, can get child to like and participate in the doctor examination even extending to loss of fear of injection and blood sampling.

Emergency Care: Almost all childhood emergencies are obvious. These include severe pain, breathing difficulty, fainting, accident, bleeding. The real question for parents is not when but where to seek emergency care. It should best be an emergency room of hospital but this should not just be left hanging as advice. As soon as you move into new area, locate and evaluate emergency medical facility and get phone/fax and internet data. Visit the facility, looking for user-friendly, quickest and easy accessed and well staffed. It may be medical center, small local hospital, HMO, private emergency care facility or even a good local General Practitioner. The point is you check out places ahead of use and make preferred list and have plan for emergency, ranging from those needing ambulance with trained paramedic to your home to those for out-of-normal time medical care not really emergency. In addition to immediate ER quality also consider backup hospital service that might be needed for appendectomy and other surgical emergency.

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