Clinical features of Kawasaki Disease

Kawasaki disease (KD), formerly known as mucocutaneous lymph node syndrome and infantile polyarteritis nodosa, is an acute febrile vasculitis of childhood.
Kawasaki disease is the leading cause of acquired heart disease in children in the United States and Japan.
Fever is characteristically high (104°F or higher), remittent, and unresponsive to antibiotics. The duration of fever without treatment is generally 1–2 wk, but it may persist for 3–4 wk. Prolonged fever is prognostic for the development of coronary artery disease.
In addition to fever, the five characteristic features of Kawasaki disease are: bilateral bulbar conjunctival injection, usually without exudate; erythema of the oral and pharyngeal mucosa with strawberry tongue and dry, cracked lips, and without ulceration; edema and erythema of the hands and feet; rash of various forms (maculopapular, erythema multiforme, or scarlatiniform) with accentuation in the groin area; and nonsuppurative cervical lymphadenopathy, usually unilateral, with node size of ?1.5 cm.
Perineal desquamation is common in the acute phase. Periungual desquamation of the fingers and toes begins 1–3 wk after the onset of illness and may progress to involve the entire hand and foot.

Other features include extreme irritability that is especially prominent in infants, aseptic meningitis, diarrhea, mild hepatitis, hydrops of the gallbladder, urethritis and meatitis with sterile pyuria, otitis media, and arthritis. Arthritis may occur early in the illness or may develop in the 2nd–3rd week, generally affecting hands, knees, ankles, or hips. It is self-limited but may persist for several weeks.

Cardiac involvement is the most important manifestation of Kawasaki disease. Myocarditis, manifested as tachycardia out of proportion to fever occurs in at least 50% of patients; decreased ventricular function occurs in a smaller number of patients. Pericarditis with a small pericardial effusion is common during the acute illness. Coronary artery aneurysms develop in up to 25% of untreated patients in the 2nd–3rd wk of illness and are best detected by two-dimensional echocardiography. Giant coronary artery aneurysms (?8 mm internal diameter) pose the greatest risk for rupture, thrombosis or stenosis, and myocardial infarction . Significant valvular regurgitation and systemic artery aneurysms may occur but are uncommon. Axillary, popliteal, or other arteries may also be involved and manifest as a localized pulsating mass.

Clinical Phases of Disease:
Kawasaki disease is generally divided into three clinical phases.
The acute febrile phase, which usually lasts 1–2 wk, is characterized by fever and the other acute signs of illness. The dominant cardiac manifestation is myocarditis. In addition, a macrophage activation syndrome may rarely be evident .
The subacute phase begins when fever and other acute signs have abated, but irritability, anorexia, and conjunctival injection may persist. The subacute phase is associated with desquamation, thrombocytosis, the development of coronary aneurysms, and the highest risk of sudden death in those who have developed aneurysms. This phase generally lasts until about the 4th wk.
The convalescent phase begins when all clinical signs of illness have disappeared and continues until the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) return to normal, ?6–8 wk after the onset of illness.

Certain clinical and laboratory findings may predict a more severe outcome. These include male gender, age <1 yr, prolonged fever, recrudescence of fever after an afebrile period, and the following laboratory values at presentation: low hemoglobin or platelet levels, high neutrophil and band counts, hyponatremia, and low albumin and age-adjusted serum IgG levels. Scoring systems based on these factors, however, have not proven sufficiently sensitive for selective treatment of patients based on risk.

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Overweight and Obesity in Children

 
Obesity and overweight are terms that are commonly used interchangeably in children, with overweight being the preferred term. As the prevalence of overweight has increased in children and adolescents, complications of overweight are now well recognized in children.
Pathogenesis:
Overweight results from a dysregulation of caloric intake and energy expenditure. A complex interplay between each individual’s genetic predispositions and the environment affects an intricate system that controls appetite and energy expenditure. Prehistoric ancestors of humans experienced long periods of food scarcity, so energy conservation and storage during times of food availability had a survival advantage.
Diagnositic Criteria for Overweight:
The diagnosis of obesity in adults is based on calculation of the BMI by dividing the weight in kilograms by the height in meters squared (kg/m²). The calculated BMI can overestimate adiposity in trained athletes or muscular children, but it is generally recognized as the most reliable method to determine healthy and unhealthy adiposity. Other methods of determining adiposity are useful, but are either too expensive to be of practical use in a clinical setting (ultrasound, CT, MRI, DEXA, total body conductivity, air displacement plethysmography), require specialized training (skinfold thickness), have poor reproducibility (waist-hip ratios), or lack extensive normative data in children (bioelectric impedance analysis). Therefore, BMI in combination with clinical assessment is sufficient to make the diagnosis.
Children’s adiposity rises in the 1st year of life, reaches a nadir around 5–6 yr of age, and then increases again throughout childhood. This is called the adiposity rebound. The 95th percentile BMI for a 4 yr old is approximately 19, but it is 25 in a 13 yr old. Consistent use of the BMI growth chart aids in early identification of children at risk for later obesity; an earlier adiposity rebound (increase in BMI younger than 5 yr of age) coincides with later obesity.
Evaluation Of Overweight Child:

  

Evaluation of overweight children and their families requires sensitivity and compassion, because the general public often perceives overweight individuals as unhealthy, unintelligent, unhygienic, and lazy. Overweight children often have decreased self-esteem, and their overweight parents may have similar psychosocial issues due to the stigma of being overweight. Obesity is a chronic medical problem that requires management in a manner similar to that of other chronic disorders. Explaining this construct to the family in an objective and nonjudgmental manner helps in building a trusting relationship that is important for successful treatment. The initial evaluation is focused on exploring dietary practices, family structure, and habits because alteration of these factors is usually the basis of successful treatment. It is also important to determine if there may be an underlying secondary cause of obesity or if there are current comorbidities from being overweight.
History:
A family history of Type 2 diabetes, a high-risk ethnicity (African-American, Hispanic, Native American), and central adiposity increase the risk of hyperinsulinism or Type 2 diabetes. Symptoms of polyuria, nocturia, polydipsia, and unexplained rapid weight loss are all associated with the onset of Type 2 diabetes. A history of maternal diabetes or obesity and being large or small for gestational age increase the risk of metabolic syndrome. Snoring, episodes of nighttime coughing fits, or excessive daytime sleepiness can be due to obstructive sleep apnea, which warrants further investigation with referral to a sleep laboratory for polysomnography. A history of wheezing, shortness of breath, or coughing can be due to asthma. Hip, knee, or leg pain is often present due to orthopedic complications. Asthma and orthopedic problems may require treatment and/or alterations in prescribed exercise programs, so identification of these problems during the initial evaluation is important. Irregular menses occur in overweight females with polycystic ovary syndrome.
Physical Findings and Laboratry Screening:
Careful screening for hypertension using an appropriately sized blood pressure cuff is important. Acanthosis nigricans suggests insulin resistance. Tanner staging is useful to identify premature adrenarche. Hirsutism, male pattern baldness, and severe acne are noted with polycystic ovary syndrome.

Treatment:

  

Successful treatment of obesity is challenging, and treatment goals vary, depending on the age of the child and the severity of complications from being overweight. Children are still growing, so severe caloric restriction and weight loss may be detrimental. Weight maintenance rather than weight loss is frequently a reasonable initial goal. As children grow in stature, BMI decreases. Weight loss should be attempted only in skeletally mature children or in those with serious complications from obesity. Weight loss should be slow (1 lb or 0.5 kg or less/wk), because more rapid weight loss requires overly restrictive dieting. An initial goal of a 10% reduction in weight is reasonable because this amount of weight loss has been shown to significantly improve overall health. Once achieved, the new weight should be maintained for 6 mo before further weight loss is attempted.

Successful long-term weight loss in adults is uncommon, despite the wide variety of diet plans and commercial products. There is a propensity to regain weight and adapt unhealthy behaviors with recurrent fad dieting. The most successful approach to weight maintenance or weight loss requires substantial lifestyle changes that include increased physical activity and altered eating habits. Similar approaches are used to prevent weight gain in children who are at risk for overweight and to promote weight maintenance or weight loss in overweight children. Therapies often combine diet, exercise, behavior modification, medications, and rarely, surgery. There is no clear and universally accepted treatment approach, but there are some generally accepted principles.
source:http://easypediatrics.com

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Hypokalemia in Children (low potassium)

Hypokalemia is generally defined as a serum potassium level of less than 3.5 mEq/L in children, although exact values for reference ranges of serum potassium are age-dependent, and vary among laboratories. It is frequently present in pediatric patients who are critically ill and reflects a total body deficiency of potassium or, more commonly, reflects conditions that promote the shift of extracellular potassium into the intracellular space.
Potassium is the most abundant intracellular cation and is necessary for maintaining a normal charge difference between intracellular and extracellular environments. Potassium homeostasis is integral to normal cellular function and is tightly regulated by specific ion-exchange pumps, primarily by cellular, membrane-bound, sodium-potassium adenosine triphosphatase (ATPase) pumps. Derangements of potassium regulation may lead to neuromuscular, GI, and cardiac conduction abnormalities.

Definition and Etiology

• Hypokalemia is defined as a serum potassium <3.5 mEq/L.
• It is a result of potassium losses in excess of replacement. Potassium can be lost through the GI tract as well as the kidneys.
  
  

  • Hypokalemia may be due to a total body deficit of potassium, which may occur chronically with the following:
    

    • Prolonged diuretic use
    • Inadequate potassium intake
    • Laxative use
    • Diarrhea
    • Hyperhidrosis
    • Hypomagnesemia
  • Acute causes of potassium depletion include the following:
    

    • Diabetic ketoacidosis
    • Severe GI losses from vomiting and diarrhea
    • Dialysis and diuretic therapy
  • Hypokalemia may also be due to excessive potassium shifts from the extracellular to the intracellular space, as seen with the following:
    

    • Alkalosis
    • Insulin use
    • Catecholamine use
    • Sympathomimetic use
    • Hypothermia
  • Other recognizable causes of hypokalemia include the following:
    

    • Renal tubular disorders, such as Bartter syndrome and Gitelman syndrome
    • Type I or classic distal tubular acidosis
    • Periodic hypokalemic paralysis
    • Hyperaldosteronism
  • Other states of mineralocorticoid excess that may cause hypokalemia include the following:
    

    • Cystic fibrosis with hyperaldosteronism from severe chloride and volume depletion
    • Cushing syndrome
    • Exogenous steroid administration, including fludrocortisone and other mineralocorticoids
    • Excessive licorice consumption
  • Other conditions that may cause hypokalemia include acute myelogenous, monomyeloblastic, or lymphoblastic leukemia.
  • Drugs that may commonly cause hypokalemia include the following:
    

    • Furosemide, bumetanide, and other loop diuretics
    • Methylxanthines (theophylline, aminophylline, caffeine)
    • Verapamil (with overdose)
    • Amphotericin B
    • Quetiapine (particularly in overdose)
    • Ampicillin, carbenicillin, high-dose penicillin
    • Drugs associated with magnesium depletion, such as aminoglycosides, amphotericin B, and cisplatin

Clinical Presentation and Physical Examination

• Symptoms: constipation, fatigue, muscle weakness, and paralysis
• Physical examination
  • Check for possible irregular heartbeat.
  • Evaluate for signs of muscle weakness/paralysis.

Differential Diagnosis

• Decreased intake as a result of low dietary intake or IV fluids without potassium
• Increased GI losses from vomiting, nasogastric suction, or diarrhea
• Increased urinary losses because of loop and thiazide diuretics
• Mineralocorticoid excess
• Liddle syndrome (autosomal dominant with increased sodium resorption)
• Bartter or Gitelman syndromes
• Amphotericin
• Hypomagnesemia

Treatment

• Administer oral or IV potassium supplements.
• Correct hypomagnesemia.
• Stop diuretics and amphotericin if possible.
   source:http://emedicine.medscape.com/article/907757-overview#a0199

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Types of Impetigo in Kids

There are many diseases that affect kids which involve the appearance of rash, among this is impetigo. Impetigo in kids is a condition where the skin appears to have sores or blisters and it often affects the area of the face about the mouth or nose. Depending on the type, it could either be due to the presence of the staph bacteria (staphylococcus aureus) or the strep bacteria (streptococcus pyogenes). Here are the common types of this disease based on the bacteria that caused them:
- Bullous impetigo - it is brought about by the presence of the staph bacteria and is common to kids of ages two and below. Its appearance on the legs, arms and trunk would look like red blisters that are pus-filled. It can exist longer than the other types, which makes longer medications necessary.
- Impetigo contagiosa or non-bullous impetigo - this type is caused by the streptococcus pyogenes bacteria and is known to be contagious, which is why it was named as such. The rash will normally begin appearing at the hands and arms, going to the nose and mouth and may even affect the other parts of the body through scratching.
- Ecthyma impetigo - among the different types, this is the most serious because it attacks not only the outer but as well as the deeper layer of the skin known as the dermis. The fluid-filled sores, which may or may not be painful, form at the legs and feet and then could spread to the other parts. In some cases, lymph nodes can also be affected with its occurrence.
Impetigo in kids may occur via transfer from an infected person through contact. When someone with the disease and other related conditions such as chicken pox, eczema, herpes or contact dermatitis scratches their skin, the bacteria can be passed on. It may also be transmitted when kids get in contact with infected things like toys, clothes or beds and it is more contagious in highly humid and warm environments such as a classroom. Thus, you must be very intentional in teaching your kids how to keep themselves protected no matter where they are.
The detection of impetigo in kids is done by conducting certain lab tests. When the bacteria are determined and the impetigo is identified, the doctor would usually give antibiotics to get rid of the source and depending on the symptoms, some other forms of medications could also be recommended. In order to guarantee complete healing, you must make sure to follow the prescriptions strictly.

Aside from impetigo, scarlet fever in kids also results to the appearance of rash. Being confused between the different diseases that bring the same symptoms can be hazardous. Finding accurate information should be your goal to avoid any confusion.

Article Source: http://EzineArticles.com/?expert=Naomi_Bethany

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Teaching Gratitude and Thankfulness

Parents Teach Gratitude and Thankfulness
Parents usually want to spoil their children and give them gifts. There is nothing wrong with that. They want their child to never lack for anything (as much as they can afford it) and have what others seem to have. They love their children and one way they demonstrate that love is to give the children gifts or experiences.
There is an imbedded problem in these gifts and experiences. When parents constantly give children toys, clothing, and/or privileges, they are not teaching their children a valuable lesson. The children not only don't understand the costs and sacrifices parents have made for them but also they develop attitudes of entitlement (the opposite of thankfulness and gratitude).
Teaching thankfulness and gratitude is not actually taught directly. It is taught by adults who model the behaviors. Parents can consistently (that is the key) reinforce gratitude and thankfulness, like many social traits, at home with their children. They do this by showing the behaviors they want their children to demonstrate. The behaviors need to be 24/7, 365 a year, for the lessons to "sink in".
Special occasions are not the only times for gratitude and thankfulness. Why can't the parent thank the child for his/her behavior towards someone else, while shopping for dinner, for showing care and concern to a sibling, etc.? Why can't the parent express gratitude for the child's existence, kindness, concerns toward him/her as well as siblings and/or others such as strangers? Why can't the parent thank the child for thinking of someone other than him/herself?
Words of praise and gratitude go a long way to both bond the child closer to the adults as well as teaching appropriate behaviors. What kind of words? How about something like these examples:

• You are such a good helper! Thank you for what you've done today.
• I really appreciate all your help. It has made my day easier and happier.
• You did such a good job of (......chore/task.....). I'm grateful that you were able to do that for me.
• I'm grateful I have such a wonderful, thoughtful child.
• Look at how well you've done that job! You are getting so grown up and I know others will appreciate you as much as I do.

Different Ages, Different Skills
Preschoolers generally do not have the developmental awareness of others' emotions/points of view or that other people may not have as much as they have. It is up to the parents to "open their eyes" to such concepts. Young children need to learn to share with others in ways that emotionally impact them. They could choose a gift to be given to a needy child during the holiday season.
Perhaps parents could, with their older children, volunteer at soup kitchens or events for the homeless or disadvantaged. For children to understand that they have more than others, they need to see that others have less than they do, perhaps even by having children clean out their toys for those outgrown or not used and donate them to centers themselves.
In some families, before holidays and birthdays, the children "make room" for the new. When gifts came unexpectedly, the children had to release equal (or more) numbers of items to others before they could keep what had just been given. This approach has another hidden agenda: cutting down on the clutter of unwanted, unused or grown out of toys and clothing stashed in closets. Cleaning out the closets makes the task the child's task rather than the adult's task. The child has the responsibility of emotionally valuing and separating from the toys and clothing. It prevents the child from stashing "stuff" to have "just in case" or for other "security" reasons.
Critical Life Skills
Parents want their children to be liked, accepted and valued by other children and adults. The quickest way to social acceptance, friendships and being important to others is to value the others aloud. Friends appreciating each other become very close friends. These relationships, parent-child and child-peers, become the foundation for the child's future relationships: employer-employee, marriage/significant other, and later on the child becomes the parent in his/her own parent-child relationships.
Your child's future is in your hands, depends on your willingness to teach him/her, and the emotional bonds your create with him/her. You are the model for your child's behavior. Be thankful and grateful for your child, because that child stretches your own heart with love shared.

Jennifer Little, Ph.D.
All children can succeed in school. Parents can help their children by teaching the foundational skills that schools presume children have. Without the foundation for schools' academic instruction, children needlessly struggle and/or fail. Their future becomes affected because they then believe they are less than others, not able to succeed or achieve or provide for themselves or their families. Visit http://parentsteachkids.com to learn how to directly help your child and http://easyschoolsuccess.com to learn what is needed for education reform efforts to be successful.

Article Source: http://EzineArticles.com/?expert=Jennifer_Little

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