Canal Road , Faisal Town ,Faisalabad

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Paediatric Department

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Paediatric Department

If your child is suffering from some kind of illness, disease and injuries, then you need a service of pediatric surgeon who has experience and qualification to deal with children related issues.

Pediatric surgeons deal with all kinds of problems faced by children and for that they need special training.

What kind of treatment given to the patients in MTH:

Pediatric surgeon in MTH diagnose, treat and manage treatment of children by using their expertise.

They provide treatment for:

 

  • They conduct surgery for abnormalities of the groin in children such as undescended testes. Hernias, hydroceles and varicoceles[A1] .
  • Repair birth defect in children through surgery
  •  Do surgery of liver lacerations, wounds.
  • Diagnosis and surgical care of tumors
  • Transplantation operations
  •  Endoscopic procedures

And also deal with other surgeries.

Common Pediatric infections:

  • Acute Otitis Media is considered to be the most common bacterial illness.
  • Diagnosis of Acute Otitis Media
  • There are signs /symptoms of middle ear inflammation such as ear tugging in front, crying, irritability, otorrhea and fever.
  •  It is also about bulging tympanic membrane, limited or absent mobility, otorrhea and air fluid level. 

Treatment given by pediatrics:

  • Treatment given by pediatrics use antibacterial agents is the best option for children and treatment will be varied according to age and illness severity.
  • Common Pathogens in AOM:
  • Streptococcus pneumonia
  • Haemophilus catarrhalis
  • Viral etiologies
  • Initial antibacterial agent choice

Acute Bacterial Sinusitis:

Sinusitis

  • Inflammation of the paranasal sinuses .It is basically chronic sinusitis.
  • · ABS Epidemiology:
  • Upper respiratory tract symptoms  include :nasal congestion ,rhinorrhea and cough etc.

Symptoms and signs of ABS:

  • There are two signs of it:
  • Respiratory symptoms
  • Nasal discharge of any quality
  • cough
  • fever
  • Diagnostic treating:
  • Use of Radiographic imaging
  • Plain films
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Viruses
  • Neither Staphylococci

Medical Treatment:

  • Amoxicillin
  • Clavulanate
  •  Cefuroxime axetil
  • Cefpodoxime
  • Macrolides
  • Antihistamines
  • Decongestants
  • Anti-inflammatory

Adjuvant Therapies

  • Antihistamines, Decongestants and Anti-inflammatories
  • Topical intranasal; steroids
  • Nasal irrigation with saline

Pediatric diseases:

  • Etiology of congenital anomalies: 

Genetic causes

  • chromosomal abnormalities, gene mutations
  • Environmental influences

Infections

  • rubella (rubella embryopathy - eliminated by vaccination), toxoplasmosis, syphilis, CMV
  • Maternal diseases
  • diabetes mellitus: diabetic embryopathy (macrosomia, cardiac anomalies, neural tube defects)
  •  drugs: thalidomide (limb malformations - phocomelia), warfarin
  • alcohol: fetal alcohol syndrome: growth retardation, facial anomalies (microcephaly, maxillary hypoplasia)
  • cigarette smoking: spontanneous abortion, placental anomalies, low birth weight, SIDS
  • irradiation

2. Perinatal Infections:

Transplacental infections:

Transplacental

  •  mostly viral and parasitic, a few bacterial infections
  • most important infections: TORCH (Toxoplasma, Other, Rubella, CMV, Herpes)
  • toxoplasma: hydrocephalus, brain calcifications, chorioretinitis
  • rubella: cataract (blindness), deafness, heart anomalies

Transcervical (ascending)

  • during pregnancy (infected amniotic fluid) or delivery
  •  Streptococci, Neisseria gonorrhoeae, herpes virus
  • usually associated with inflammation of placental membranes (chorioamnionitis) and umbilical cord (funisitis)

Congenital anomalies

  • structural defects present at birth
  • important cause of infant mortality

Malformations

  • primary error of morphogenesis (abnormal development)

  • usually multifactorial

  • single or multiple organs may be involved

Disruptions

  • secondary destruction of normally developed organ
  • not heritable (no risk of recurrence in subsequent pregnancies)
  • amputation of limbs by amniotic bands

Deformations

  • compression of growing fetus (uterine constraint)
  • malformed uterus, leiomyoma, multiple fetuses

Agenesis

  • the complete absence of the organ

Hypoplasia

  • - incomplete development or underdevelopment of the organ

Atresia

  • absence of opening of the hollow organ (intestine, bile ducts)

Etiology of congenital anomalies

Genetic causes

  • chromosomal abnormalities, gene mutations

Environmental influences

  • Infections
  • rubella (rubella embryopathy - eliminated by vaccination), toxoplasmosis, syphilis, CMV
  • Maternal diseases
  • diabetes mellitus: diabetic embryopathy (macrosomia, cardiac anomalies, neural tube defects)
  • drugs: thalidomide (limb malformations - phocomelia), warfarin
  • alcohol: fetal alcohol syndrome: growth retardation, facial anomalies (microcephaly, maxillary hypoplasia)
  • cigarette smoking: spontanneous abortion, placental anomalies, low birth weight, SIDS
  • irradiation

Perinatal infections

Transplacental

  • mostly viral and parasitic, a few bacterial infections
  • most important infections: TORCH (Toxoplasma, Other, Rubella, CMV, Herpes)
  • toxoplasma: hydrocephalus, brain calcifications, chorioretinitis
  • rubella: cataract (blindness), deafness, heart anomalies

Transcervical (ascending)

  • during pregnancy (infected amniotic fluid) or delivery
  • Streptococci, Neisseria gonorrhoeae, herpes virus
  • usually associated with inflammation of placental membranes (chorioamnionitis) and umbilical cord (funisitis)

Prematurity

  • gestational age less than 37 weeks
  • second most common cause of neonatal mortality
  • higher incidence of morbidity

Risk factors:

  • premature rupture of membranes
  • intrauterine infections (chorioamnionitis)
  • anomalies of placenta, uterus and cervix
  • twin pregnancy

Complications:

  • - respiratory distress syndrome
  • - necrotising enterocolitis
  • - CNS bleeding

Fetal growth restriction

  • one-third of infants born in term but underground (weight less than 2.500 g): „small-for-gestational-age“ (SGA)
  • not only increased morbidity and mortality in perinatal period, but also problems in adult life (cerebral dysfunction, learning disability)

Causes:

Fetal

  • chromosomal disorders, congenital anomalies, congenital infections (TORCH group)
  • symmetric growth restriction (all organ systems affected equally)

Placental

  • impaired uteroplacental supply
  • placenta previa, placental abruption, placental infarction
  • asymmetric growth restriction (brain spared relative to visceral organs)

Maternal

  • preeclampsia, chronic hypertension, alcohol, drugs, smoking, malnutrition

Unknown

Respiratory distress syndrome (RDS)

Risk factors

  • prematurity (60% before 28th week, only 5% after 37th week)
  • maternal diabetes, cesarean section, twins

Pathogenesis

  • immature lungs cannot synthesize surfactant (complex of phospholipids reducing surface tension within alveoli) → alveoli tend to collapse → greater inspiratory effort → atelectasis (loss of lung volume) → hypoxia → epithelial and endothelial damage → hyaline membranes

Morphology

  • airless, heavy lungs, mottled color
  • congestion, solid appearance with collapsed alveoli
  • hyaline membranes (necrotic cellular debris, extravasated fibrin)

Complications (administration of high concentration of oxygen)

  • Bronchopulmonary dysplasia
  • arrested development of alveolar septation → reduced number of mature alveoli and interstitial fibrosis → honeycomb lung

Retrolental fibroplasia

  • retinal vessels proliferation → blindness
  • Necrotizing enterocolitis (NEC)
  • premature infants
  • intestinal ischemia (hypoperfusion)
  • bacterial colonisation of the gut
  • administration of formula feeds

Macro:

  • terminal ileum, cecum, right colon most commonly involved
  • distended, friable, congested or gangrenous gut segment
  • intestinal perforation → peritonitis

Micro:

  • mucosal or transmural necrosis
  • ulceration
  • submucosal gas bubbles
  • reparative changes: granulation tissue, fibrosis → post-NEC strictures

Sudden Infant Death Syndrome

  • “sudden death of an infant under 1 year of age which remains unexplained even after complete autopsy, examination of the death scene and revision of clinical history“
  • infant usually dies while asleep („crib death“)
  • leading cause of death in infancy (USA: 3,000 cases annually)
  • in 90% of cases infants younger than 6 months
  • unknown cause; hypothesis: delayed development of some regions of brainstem (arcuate nucleus) → impaired arousal response to noxious stimuli

Risk factors:

Maternal

  • young age, smoking during pregnancy, drug abuse (either parent), short intergestational intervals, low prenatal care, low socioeconomic status

Infant

  • brain stem abnormalities (defective arousal and cardiorespiratory control), prematurity, male sex, multiple birth, SIDS in earlier sibling, respiratory infections

Environment

  • prone sleep position, sleeping on soft surface, hyperthermia, passive smoking

Autopsy findings

  • multiple petechiae on thymus, pleura and epicardium
  • lung congestion, lung edema
  • brain stem abnormalities (hypoplasia of arcuate nucleus, decrease of neuronal population)

SIDS is diagnosis of exclusion; to be excluded:

  • infections (viral myocarditis, bronchopneumonia)
  • congenital anomalies
  • fatty acid oxidation disorders (medium chain acyl-coenzyme A dehydrogenase deficiency)
  • arrhythmia (prolonged QT interval)
  • traumatic child abuse („shaken baby syndrome“)

Fetal hydrops

  • generalized edema of fetus (hydrops fetalis) or localized forms (pleural or peritoneal effusion)

Causes:

  • fetal anemia
  • immune hydrops (Rh and AB0 incompatibility)
  •  non-immune hydrops (α-thalassemia, parvovirus B19)
  • chromosomal abnormalities (trisomies, Turner syndrome)
  • cardiovascular abnormalities (heart defects)
  • infections (CMV, syphilis, toxoplasmosis)
  • twin-twin transfusion“ syndrome

Immune hydrops

  • hemolysis of fetal RBCs induced by maternal antibodies
  • Rh or AB0 blood group incompatibility between mother and fetus
  • fetus inherits blood group antigens from father, that are foreign to mother (mother Rh-negative - fetus Rh-positive; mother 0 - fetus A or B)
  • fetal RBCs reach maternal circulation (during last trimester of pregnancy or during delivery) → mother sensitized and develops antibodies
  • next pregnancy: antibodies traverse placenta → destruction of fetal RBCs → fetal anemia → tissue ischemia → cardiac failure → edema

Morphology

  • pale fetus and placenta
  • hepatosplenomegaly (congestion from cardiac failure)
  • hyperplasia of erythroid precursors within bone marrow
  • extramedullary hematopoiesis (liver, spleen, kidney, lungs)
  • presence of immature red cells in peripheral blood (erythroblastosis fetalis)
  • hemolysis → unconjugated hyperbilirubinemia → toxic damage of brain (basal ganglia and brainstem) →yellow hue due to deposition of bilirubin pigment („kernicterus“)

Tumors of Infancy and Childhood

Tumor-like lesions

  • Hamartoma = focal overgrowth of tissue in organ where it normally occurs
  • linkage between malformations and true tumors (dividing line often not clear and variously interpreted)
  • hemangioma, lymphangioma, heart rhabdomyoma
  • Choristoma = presence of normal cells in abnormal location
  • little clinical significance, may be confused with true tumors
  • pancreatic tissue in stomach wall, adrenal cortex in kidney, lung, ovary

Benign tumors

Hemangioma (cavernous or capillary)

  • skin (face, scalp)
  • flat to elevated red blue mass („port wine stain“)
  • enlargement or spontaneous regression
  • rarely component of hereditary disorders (von Hippel-Lindau sy, Sturge-Weber sy)

Lymphangioma

  • cystic and cavernous lymphatic spaces
  • skin or deep tissues (neck, axilla, mediastinum, retroperitoneum)
  • tend to enlarge after birth → compression of adjacent structures
  • component of Turner sy

Sacrococcygeal teratoma

  • most common germ cell tumor in childhood
  • 10% of cases associated with congenital anomalies of cloacal region and neural tube defects (spina bifida, meningocele)
  • majority of cases mature (benign)
  • rarely immature (malignant)

Malignant tumors

  • hematopoietic system, CNS and soft tissues most commonly involved
  • primitive („embryonal“) microscopic appearance: „small round blue cell tumors“
  • tendency to differentiate into more mature elements
  • improved survival due to chemotherapy and radiotherapy → effort paid to minimizing of delayed adverse effects of treatment (secondary neoplasms)

Neuroblastoma

  • derived from primordial neural crest cells populating adrenal medulla and sympathetic ganglia
  • second most common solid malignancy in childhood (7-10% of all pediatric neoplasms; 50% of all pediatric malignancies)
  • most sporadic, a few autosomal dominant transmission (often multiple)
  • rom minute nodules to large masses

Macro

  • - soft, gray-tan tissue, areas of necrosis, cystic change and hemorrhage

Micro

  • solid sheets of small primitive cells (neuroblasts) with dark nuclei and scant cytoplasm
  • faintly eosinophilic fibrillary background (processes of neuroblasts)
  • Homer-Wright rosettes
  • signs of maturation (spontaneous or therapy-induced):
  • ganglion cells admixed with neuroblasts         (ganglioneuroblastoma)
  • ganglion cells and Schwann cell stroma (ganglioneuroma)
  • metastatic spread to liver, lungs and bones
  • production of catecholamines → metabolites vanillylmandelic acid (VMA) and homovanillic acid (HVA) within urine (screening markers)

Retinoblastoma

  • most common malignant eye tumor in childhood
  • may be congenital
  • sometimes spontaneous regression
  • high incidence of second primary tumors (osteosarcoma, soft tissue tumors)
  • sporadic (always unifocal and unilateral) or familial (often multiple and bilateral)
  • from neuroepithelial cells of posterior retina

Macro

  • nodular mass with satellite seedings

Micro

  • small rounded cells with large dark nuclei
  • Flexner-Wintersteiner rosettes
  • metastatic spread to CNS, bones and lymph nodes
  • poor vision, strabismus, whitish hue to pupil (“cat’s eye reflex”)
  • untreated fatal, early treatment (enucleation, chemotherapy, radiotherapy) → survival

Nephroblastoma (Wilms’ tumor)

  • most common primary renal tumor in children

Macro

  • large well-circumscribed mass
  • soft, homogeneous, tan to gray, areas of hemorrhage, necrosis or cystic degeneration

Micro

  • histology reveals some recapitulation of nefrogenesis
  • three components: blastema, stroma and epithelium
  • blastema: sheets of small blue cells
  • stroma: spindle cells (fibroblasts), heterologous elements (skeletal or smooth muscle, cartilage, osteoid, neurogenic tissue)
  • epithelium: abortive tubules and glomeruli

Clinical presentation

  • palpable abdominal mass, fever, abdominal pain, hematuria, intestinal obstruction
  • generally good prognosis with appropriate therapy (nephrectomy and chemotherapy)

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