21: 12-year-old female with fever Flashcards
Modified Centor Criteria (also called McIsaac Score):
Give one point for each positive response:
Tonsillar exudate or erythema Anterior cervical adenopathy Cough absent
Fever present:
Age 3 to 14 years: +1 point
Age 15 to 45 years: 0 points
Age over 45 years: -1 point
Influenza Complications - Prevalence, Epidemiology, Risk Factors, & Treatment
The two most common complications of influenza: bacterial pneumonia
1. streptococcal pneumonia present in about 2-3 % of outpatient children and up to 14% of hospitalized children
2. staphylococcal pneumonia
otitis media (10-50% of children with influenza)
Less common complications of influenza: neurologic
- aseptic meningitis
- Guillain-Barre syndrome
- febrile seizures
Rare complications of influenza:
myositis myocarditis
Epidemiology, RF, Tx
Epidemiology
It is estimated that 15 to 42% of preschool and school age children are infected with influenza each year. While for many children the disease is self-limiting and they improve in two to five days, complications, serious illness and hospital stays are more common in children less than five years of age. Children less than two years of age are especially vulnerable.
Risk factors
Risk factors for developing complicated influenza infection include chronic pulmonary disease including bronchopulmonary dysplasia, asthma, cystic fibrosis and conditions that affect the ability to handle respiratory secretions or increase the risk of aspiration. Others who have increased risk include those who have congenital heart disease, metabolic conditions (i.e. diabetes mellitus) chronic renal disease, immunosuppression or children who are on long-term aspirin therapy, (i.e. Kawasaki’s).
Treatment
Most streptococcal pneumonia can be treated using amoxicillin 90mg/kg/day divided in three dosages for 7 to 10 days. In children 3 months to adolescence, amoxicillin is the recommended first line agent. In school age children who have a clinical presentation consisted with atypical pneumonia macrolides such as azithromycin, 10mg/kg on day one followed by 5mg/kg on days two through five, should be used.
Influenza - Transmission, Prevention, Disease Course, and Signals of Complications
Transmission
Direct transmission; airborne; and through hand-to-eye, hand-to-nose, or hand-to-mouth transmission, either from contaminated surfaces or from direct personal contact. Infected children are advised to stay out of school until most symptoms have improved and the child has been afebrile for 24 hours.
Prevention
Infection control and immunization of high-risk groups, such as children, the elderly, health care workers, and people who have chronic illnesses such as asthma, diabetes, heart disease, or are immuno-compromised.
Disease Course
The fever that comes with influenza lasts for three to five days. The cough and feeling tired can last longer; some people will have a cough and still feel tired about two weeks after they were initially sick.
Signals of Complications Symptoms last longer than five to seven days without any relief Difficulty breathing Worsening cough Difficulty maintaining hydration
Type II diabetes
has become more common among 6-19 year olds, comprising 8 to 45 percent of all new cases of diabetes.The prevalence of diabetes mellitus in persons younger than 20 years old is about 1 in 400.
Risk factors - BMI at or above the 85 percentile, an increased fasting glucose level of 100mg/dL, and an elevated fasting insulin level.
Recommended screening - Screen all children at age 10 who have a BMI >85 percentile and risk factors for diabetes or >95 percentile without risk factors, rechecking every two years thereafter.
High cholesterol (serum cholesterol levels greater than 200mg/dL) - has been found in 10 percent of children 2 to 19 years of age. This is higher than it was previously
Risk factors - The strongest risk factor is elevated BMI.
Recommended screening - Check a fasting lipid profile on every child with a BMI of >85 percentile. The goal total cholesterol is 170 mg/dL. The goal low-density lipoprotein (LDL) is 130 mg/dL.
Treatment - Initial treatment includes diet and exercise. Drug treatment is recommended for children who have an LDL >190 mg/dL or and LDL > 160 mg/dL with risk factors. Drug treatment is only recommended for children who are older than 10 and who are either Tanner stage 2 (male) or have achieved menarche.
Hypertension incidence in children has increased from 1-3% to 5-11%.
Risk factors - The strongest risk factor is obesity.
Complications - Hypertension in children can lead to hypertension in adults and put them at risk for cardiovascular complications.
Other complications of obesity
Musculoskeletal disorders such as Blount’s disease (progressive bowing of the legs) or slipped femoral epiphysis (leads to hip or knee pain).
Gastrointestinal problems including steatosis and gallbladder disease. New recommendations include screening for steatosis at age 10 if BMI is greater than 95 percentile, or if greater than the 84-94 percentile but with risk factors and every 2 years thereafter with an AST and ALT and refer to gastroenterology for levels that are twice the upper limit of normal.
Gynecological problems including early menarche and polycystic ovary syndrome can also be seen in overweight females.
Skin complaints such as acanthosis nigricans (darkening of the skin around the neck), and intertrigo (inflammation of skinfolds caused by skin-on-skin friction, initially presents as red plaques, almost in a mirror image, on each side of the skin fold) are more common among overweight children.
Psychosocial problems including: stigmatization, bullying, low self-esteem, and depression.
Obstructive sleep apnea, asthma, pseudotumor cerebri are also more common among overweight children.
Pediatric Weight Management Recommendations
- Prevention Plus
- starting place for all children and adolescents who are overweight or obese
If no improvement after 3-6 months use (5-2-1-0) counseling
5 serving of fruits and vegetables
2 hours of screen time
1 hour of physical activity
0 sugar-sweetened beverages Family meals
Healthy breakfast
Allow child to self-regulate meals

2. Structured Weight Management
1. for children who have no had improvement on prevention plus
2. after 3-6 months if no improvement for all children with BMI > 85-94 percentile
Especially if BMI > 95% or health risks - Above plus: Reduce energy-dense foods
Structured meals: plan 3 meals a day and 1 to 2 healthy snacks and no other food
1 hour of screen time
Diet and activity monitoring for 3 to 6 months Monthly office visits
Additional support by dietitian, counselor, or exercise therapist as needed

3. Comprehensive Multidisciplinary Intervention
1. next step for children ages 2-5; >95 percentile or ages 6-18; 95-99 percentile
Above plus referral to multidisciplinary obesity care team and behavioral modification
- Tertiary Care Intervention
- for ages 6-18, final step
Above plus referral to pediatric tertiary weight management center
Wheezes
Expiratory or inspiratory spasms of the bronchioles. Wheezes are high pitched and continuous. A wheeze that is entirely inspiratory and louder in the neck indicates partial obstruction of the airway in the neck and is called stridor. If wheeze is localized it suggests a partial obstruction of the bronchus- and can be inspiratory or expiratory. In asthma, wheezes may be heard in both phases. In chronic bronchitis, wheezes can clear with coughing.
Rhonchi
Expiratory or inspiratory continuous sounds that are lower in pitch than wheezes and are more like snoring sounds. They are associated with larger, bronchial secretions and airway narrowing. They usually clear after coughing.
Pulmonary Findings Indicating Consolidation
Egophony
When the patient says “E” the examiner hears “A.”
Tactile fremitus
The examiner places the ball of the hand on symmetric areas of the lungs. The examiner feels the vibration through the bones of the hands. When a patient speaks “99” or “toy boat,” if the examiner feels increased areas of vibration it signifies consolidation and the sensation of decreased vibration signifies effusion.
Dullness to percussion
Could signify an effusion or consolidation in areas that are dull, but it can be hard to determine in infants.
Crackles
Crackles are a sign of fluid in the lungs and may be a sign of a consolidation. A crackle occurs when an abnormally closed airway opens during inspiration or closes at the end of expiration. In contrast to wheezing, which is continuous, crackles are a discontinuous sound. The term “fine crackles” characterizes high frequency components and short duration. “Coarse crackles” (aka rales) are lower frequency and longer duration.
Crackles may appear in early, mid, or end-inspiration or in expiration. Early inspiratory crackles are probably generated in more proximal airways than late inspiratory crackles. In acute pneumonia, edema and infiltration of inflammatory cells in lung tissue may narrow the bronchi and cause fine crackles at mid-inspiration. In resolving pneumonia, inflammatory cells tend to accumulate, edema diminishes, and the lung parenchyma becomes drier. Coarser, late inspiratory crackles are thus appreciated at this stage.
More diffuse lung infections may result in generalized crackles or wheezing.
Whispered pectoriloquy:
When you have the patient whisper words, “one-two-three,” you hear it louder with the stethoscope over areas of consolidation or cavity.
Influenza Treatment
Antivirals such as zanamivir, oseltamivir, amantadine, and rimantadine can decrease the duration of influenza symptoms by approximately 24 hours, but they are only recommended when given within the first 48 hours of illness.
The only indications for starting antivirals for influenza after 48 hours of onset of illness are:
- if the patient has moderate to severe community acquired pneumonia with findings consistent with influenza
- if the patient is clinically worsening at the time of the initial outpatient visit
Management of Elevated Cholesterol in Children
“If LDL is great than 190 mg/dl, initial recommendation is 6 months of diet and exercise treatment. If there is no improvement after 6 months and child is age 10 or older recommendation is to start treatment with a statin in discussion with the family.
For children who have other cardiac risk factors(ie. hypertension, Diabetes mellitus type 1 or 2, Kawasaki disease) or family risk factors including cardiac event in male parent, grandparent, uncle less than age 55 or female parent, grandparent, aunt less than age 65 the decision could be made to initiate therapy at a lower LDL range.
For children with LDL of greater than 190mg/dl it is likely they have a familial hypercholesterolemia and should be referred to a pediatric lipid specialist.
Differential Acute Pediatric Cough
Upper respiratory infections
–Can cause a low-grade fever, rhinorrhea, sneezing, nasal congestion and cough.
–Lasts about one week.
–Nasal discharge can begin as clear and gradually progress to colored, but that isn’t a predictor of bacterial involvement.

Asthma exacerbation
–Asthma is a chronic illness of inflammation and spasm in the bronchi and bronchioles that can be triggered in the setting of viral illnesses such as influenza or respiratory syncytial virus – known as an asthma exacerbation.
–Children can develop wheezing when they are older, however many children with asthma start with problems when they are less than five years old.
Bronchiolitis
- -Caused by viruses such as respiratory syncytial virus (RSV).
- -Seen in young children with the incidence peaking at 6 months of age.
- -Often starts as a viral illness and progresses to wheezing, cough, dyspnea, and cyanosis.
- -Infants require supportive treatment including oxygen if hypoxic, while they are recovering.
