14 Flashcards
Antihistamines/decongestants in toddlers - age appropriateness
The U.S. Food and Drug Administration published an advisory in January 2008 that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. This was based upon the lack of demonstrated benefit along with reported adverse events, including fatal overdoses. Therefore, the mother should be counseled not to give the OTC antihistamine/decongestant to Rebecca (B).
Diff dx for Hx of fever and cough - 5
Acute otitis media
Typically develops 3-5 days after onset of upper respiratory symptoms.
One of the more specific symptoms is otalgia (ear pain, tugging at ears).
Other symptoms include fever, irritability, cough, anorexia, and, less commonly, vomiting and diarrhea.
Otitis media is a common complication of URIs in this age group.
Sinusitis
Most episodes of sinusitis are thought to begin with a viral URI, followed by superinfection of pathogenic bacteria (the same organisms as in OM).
Persistent URI symptoms (> 10 days) with day and night cough are common in pediatric sinusitis.
Upper respiratory tract infection
Depending on the viral agent, the presentation of the common cold is variable.
Throat irritation, sneezing, nasal stuffiness, rhinorrhea, cough, fever, and irritability are common symptoms of a URI.
Allergic rhinitis
Rhinitis is sometimes a symptom of allergies. No fever is present.
Seasonal rhinitis usually corresponds with the presence of environmental allergens such as airborne pollen, while perennial rhinitis is usually a manifestation of indoor allergens/irritations such as dust mites, animal dander, mold and tobacco.
Pneumonia
The typical childhood presentation of bacterial pneumonia (much less common than viral) is the abrupt onset of high fever, a productive cough, an ill appearance and sometimes chest pain.
PE can reveal dyspnea and tachypnea.
Viral pneumonias more often present with moderate fever, a nonproductive cough and gradual onset of upper respiratory tract symptoms (younger children often present with less specific symptoms).
What part of toddler exam to do first and which to do last?
First quick glance in the eyes for conjunctiva erythema or discharge
Last is ears and oral cavity
Examining TM
Position nml retracted bulging
Color gray red yellow
Opacity translucent opaque
Mobility absent reduced normal
Acute otitis media
Ear exam
Other ear findings that may appear -3
bulging, white and poorly mobile tympanic membranes
Other findings associated with AOM:
Bulli (bullous myringitis)
Radial vascular dilation (bicycle-spoke distribution)
Marked erythema, with “cobblestone” appearance of the TM.
RF for AOM
Risk factors for otitis media include:
Daycare attendance
Tobacco exposure
Allergies
Bottle propping at bedtime
Pacifier use
Drinking formula from a bottle rather than breastfeeding
Significant family history of AOM
Male gender
Lower socioeconomic status
Respiratory allergies
Children with conditions affecting craniofacial structure (cleft palate, Down syndrome) and genetic predisposition (Native Americans) are also at greater risk.
Bacterial organisms in AOM 4
Viral organisms in AOM 3
Bacterial causes of AOM are found in the following percentages:
Streptococcus pneumoniae 25–50%
Haemophilus influenzae, nontypeable 15–52%
Moraxella catarrhalis 3–20%
Streptococcus pyogenes <5%
Viruses also play a significant role in the pathogenesis of otitis media:
Viruses are known either to alter the mucosal lining, thereby increasing bacterial colonization of the nasopharynx, or to act as a sole pathogen in AOM.
When a virus is a co-pathogen with bacteria, the acute infection may be less responsive to antibiotic therapy.
Viruses known to be particularly associated with AOM are respiratory syncytial virus (RSV), influenza and rhinovirus.
Tx of AOM
age groups
In general, AOM resolves spontaneously 50-80% of the time without complications.
High dose amoxicillin (A) (80–90 mg/kg/day) is the appropriate first-line treatment . You prescribe a course of amoxicillin and schedule a follow-up visit in two weeks to reassess her ears and language concerns.
First-line Therapy for AOM
Amoxicillin remains the preferred first-line therapy for AOM because at appropriate dosages it is effective against susceptible and intermediately resistant S. Pneumoniae due to alterations in their penicillin-binding proteins. Amoxicillin also:
is inexpensive
tastes good
has a relatively good safety profile, and
is narrow in its spectrum of antibacterial activity.
The American Academy of Pediatrics/American Academy of Family Physicians 2013 AOM Diagnosis and Management Guidelines recommend considering high dose amoxicillin/clavulanate in children with concurrent purulent conjunctivitis due to its greater efficacy along with the increasing prevalence of nontypeable Haemophilus influenzae.
All children age 6 months to 2 years old with bilateral acute otitis media, whether symptoms are mild or severe, are treated with antibiotics.
The following algorithm is used for children aged 6 months to 2 years with unilateral acute otitis media, or children over 2 years with unilateral or bilateral acute otitis media.
Use antibiotic therapy in these cases:
In these cases, clinician and parent can discuss
antibiotic therapy vs. additional observation and close followup*
AOM with severe symptoms, defined as:
Toxic-appearing child, or
Persistent ear pain for 48 hours, or
Fever > 39 C (102.2) within the past 48 hours
AOM (with mild or severe symptoms)
AOM with mild symptoms, defined as:
Mild ear pain and
Temperature < 39 C in past 48 hours
*The observation option should be offered only to families in which good follow-up can be assured and antibiotics can be started should the child’s condition worsen or not improve in 48 to 72 hours.
Ear PE for OME
What other tests should be done 2
amber, non- or poorly mobile, opaque and retracted tympanic membrane (A) are more indicative of OME
assessment of language development (A) and hearing are critical because of the association of persistent middle ear fluid with conductive hearing loss and possible language delay. Hearing tests are recommended whenever a language delay, learning problem, or hearing loss is suspected.
Tx of persistent OME
Treatment of Persistent OME
Conservative Management
Children with persistent effusion for three months who have normal speech and language – and no other risk factors for hearing loss – should have a hearing assessment. If the assessment is normal and there are no other risk factors (i.e., developmental delay, learning problems, Down syndrome, etc.), the child can be followed at 3- to 6-month intervals until the effusion resolves or the child develops a hearing deficit, language delay, or structural abnormality of the tympanic membrane or middle ear.
Although antibiotics and/or steroids may offer a small, transient benefit, neither is currently indicated.
Counseling and controlling environmental factors are of great importance in all children with persistent effusions.
American Academy of Pediatrics guidelines on the management of OME note that it is important to “distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and the need for intervention.”
Myringotomy and Tube Placement
Bilateral myringotomy (incision made in the TM) with tube placement becomes an additional treatment option in a child with chronic OME and bilateral hearing loss. Using duration-based criteria alone (i.e., duration of effusions) in children without other risk factors, however, tube placement apparently does not improve developmental outcomes.
At this time, in a child with persistent OME, the individual child’s circumstances (risk factors such as daycare attendance, young age, otitis-prone family or symptoms with OME such as recurrent AOM), results of hearing/language assessments, and parental concerns should all go into the decision of when to refer for bilateral myringotomy with tube placement.
when to Consider Tympanostomy Tubes
Tube placement should be strongly considered in children with persistence of the middle ear fluid, a conductive hearing loss, and associated language delays.
If only mild hearing loss is noted, and no other risk factors (such as language delay), “watchful waiting” for another three to six months with a follow-up hearing test would be an option. There is no good evidence that early placement of tympanostomy tubes in otherwise healthy children with persistent OME improves developmental outcomes at 3, 4, 6, or 9-11 years of age.
Watchful waiting would not be appropriate, however, for a patient who had suspected structural abnormalities to the eardrum or middle ear space or a patient developing problems with otalgia.
Denver 2 dev screening tool
The Denver II is a standardized developmental screening tool for children 0-6 years of age. Domains assessed are:
Social
Language
Fine motor
Gross motor
This screening tool helps identify children who may have developmental delays. The screen reports the percentage (25%–90%) of children who successfully perform a specific task. To interpret the results appropriately, pre-established, specific methods for administering the test must be followed.
Subsequent referral for more definitive developmental testing should follow for children with concerning, or “suspect,” Denver II screens.
Types of hearing tests 4
Potential Testing Performed by an Audiologist
Tympanogram An objective method for evaluation of the mobility of the tympanic membrane.
Conventional audiometry Behavioral test measuring auditory thresholds in response to speech and frequency-specific stimuli presented through earphones.
Visual reinforcement audiometry (VRA) Behavioral test measuring response of the child to speech and frequency-specific stimuli presented through speakers in a sound-treated room.
Otoacoustic emissions (OAE) Physiologic test measuring cochlear function in response to presentation of a stimulus. Primarily used in newborn assessments.
Visual Reinforcement Audiometry (VRA)
VRA is an appropriate audiologic evaluation for children from about 6 months to 2.5 years of age, but requires a sound-treated room and an experienced audiologist (i.e., it is not a useful screening tool). The child is put in a booth and is typically sitting on a parent’s lap. It is referred to as behavioral testing because it measures a child’s response to both speech and frequency-specific stimuli presented through speakers. Response to the stimuli is rewarded typically with a three-dimensional animated toy. This test is not ear-specific, as it assesses hearing only in the better ear.
Conventional audiometry with headphones generally is not possible until the child is 4 years or older.
