23: 5-year-old female with sore throat Flashcards
Complications of GABHS Pharyngitis
Scarlet fever is associated with GABHS pharyngitis and usually presents as a punctate, erythematous, blanching, sandpaper-like exanthem. The rash is found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia’s lines). The pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry tongue).
Complications of strep throat are usually divided into suppurative and non-suppurative categories. Even though rheumatic fever and post-streptococcal glomerulonephritis are serious, they are relatively rare. Other complications include: peri-tonsillar abscess, mastoiditis, meningitis, and bacteremia.
Vaccinations - Withholding & Contraindications
When to withhold vaccinations
Patients with recent exposure to infectious diseases, or patients who have a mild illness (with or without fever), should receive their vaccines. However, if a patient has a moderate to severe illness (including high fever, otitis, diarrhea, and vomiting) then vaccines should be postponed until they are recovering and are no longer acutely ill.
Contraindications
Allergy or sensitivity to a specific vaccine is a contraindication for only that specific vaccine. While there are no absolute contraindications to immunizations in general, there are some conditions that have cautions or contraindications for specific vaccines. For example, immunodeficiency (either in the patient or in a household member) such as HIV infection or chemotherapy are contraindications for certain vaccines.
Most states require the following vaccines prior to school entrance:
Five DTaP Four polio Three hepatitis B Two MMR Two varicella
The well-child exam for any age can be broken down into five major components:
- history
- physical exam including measurements and vision and hearing screenings
- assessment of behavior and development
- immunizations and lab screening
- anticipatory guidance
Childhood overweight and obesity are related to –
Health risks: Risk factors for heart disease, such as high cholesterol and high blood pressure, occur with increased frequency in overweight children and adolescents compared to children with a healthy weight.
Medical conditions: Type 2 diabetes, previously considered an adult disease, has increased dramatically in children and adolescents. Overweight and obesity are closely linked to type 2 diabetes.
Increased risk of adult obesity: Overweight adolescents have a 70% chance of becoming overweight or obese adults. This increases to 80% if one or more parent is overweight or obese.
Increased morbidity and mortality rates:Overweight or obese adults are at risk for a number of health problems including heart disease, type 2 diabetes, high blood pressure, and some forms of cancer.
Anticipatory Guidance Five-Year-Old Well-Child Exam
Nutrition
Remind parents to have their children eat whole grains like brown rice and wheat bread. It’s also important to limit the amount of sugary drinks that kids have, even juice. No more than four to six ounces of juice a day is recommended.
Physical activity
Children should get 60 minutes of physical activity every day.
Limiting screen time (television, computer, and video games) to two hours a day is helpful to keep children active. It’s also good to keep TVs, games, and computers out of kids’ bedrooms.
Oral health
Schedule dental appointment. Teach child to brush teeth.
Discuss flossing, fluoride, sealants.
Sexuality education
Expect normal curiousity of genitalia and sex.
Explain good touch/bad touch and that certain body parts are private.
Selective screening for lead toxicity at periodic visits should be done if any of the following questions is positive:
Does your child live in or regularly visit a house or child care facility built before 1950?
Does your child live in or regularly visit a house or child care facility built before 1978 that is being or has recently been renovated or remodeled (within the last six months)?
Does your child have a sibling or playmate who has or did have lead poisoning?
The following children need selective screening for anemia at periodic visits:
At risk of iron deficiency because of special health needs Low-iron diet (i.e. nonmeat diet) Environmental factors (i.e. poverty, limited access to food)
Tuberculosis screening guidelines:
Children who should have annual Tuberculin Skin Test:
- -Children infected with HIV
- -Incarcerated adolescents
- -Validated Questions for Determining Risk of Latent
Tuberculosis Infection in Children in the United States:
- -Has a family member or contact had tuberculosis disease?
- -Has a family member had a positive tuberculin skin test?
- -Was your child born in a high-risk country (countries other than the United States, Canada, Australia, New Zealand, or Western European countries)?
- -Has your child traveled (had contact with resident populations) to a high-risk country for more than one week?
GABHS Pharyngitis Treatment
Penicillin V (50 mg/kg in 2-3 divided doses for 10 days, or 250 mg 2-3 times a day for children less than 27 kg) is the antibiotic of choice for strep pharyngitis due to low cost, narrow spectrum of activity, safety and effectiveness. Penicillin V is recommended as a first-line treatment for strep pharyngitis by several organizations (AAFP: American Academy of Family Physicians, AAP: American Academy of Pediatrics, AHA: American Heart Association, WHO: World Health Organization, and IDSA: Infectious Disease Society of America).
Penicillin G IM is an appropriate choice when the patient is otherwise unlikely to finish the entire course of oral antibiotics. An injection can cause significant discomfort and has an increased risk of anaphylaxis although a form of injectable penicillin mixed with benzathine/procaine (Bicillin C-R) lessens discomfort.
Amoxicillin liquid is often given to children instead of penicillin because it tastes better. However, penicillin has a narrower spectrum of activity effective against strep and is less likely to contribute to antimicrobial antibiotic resistance. Amoxicillin dosing is 50 mg/kg divided 2-3 times a day for 10 days. Single dose amoxicillin is not approved for children younger than 12.
First generation cephalosporins (Cephalexin and Cefadroxil) are as effective as penicillins. They also have a broader spectrum of activity than penicillin and may contribute to antibiotic resistance. They are recommended for patients who have an allergy to penicillin that is not an immediate-type hypersensitivity. Cephalexin dosing is 25-50 mg/kg divided 2-3 times a day for 10 days.
Macrolides (Erythromycin ethlysuccinate or Erythromycin estolate) are reserved for patients with penicillin allergy. They also have a broader spectrum of activity than penicillin and may contribute to antibiotic resistance. Azithromycin or clarithromycin may have fewer gastrointestinal side effects than erythromycin.
Differential of Pediatric Fever, Sore Throat, Cough, & Rash: Most Likely / Most Important Diagnoses
Viral pharyngitis
Viral pharyngitiscaused by common respiratory viruses (rhinovirus, coronavirus, and adenovirus) is the most common cause of sore throat. The presentation of viral pharyngitis can be variable. It can present with throat irritation, fever, a rash, rhinnorhea, and cough. Viral pharyngitis is often the first symptom of an viral upper respiratory infection. The most common clinical symptoms include cough, congestion and rhinorrhea but sore throat can appear first. Stomatitis and conjunctivitis are also suggestive of a viral etiology. Fever may be present, but it is usually low grade, and children may develop a rash (viral exanthem).
Group A Beta-hemolytic Streptococcus pharyngitis
GABHS is the most common bacterial cause of pharyngitis, and is important to identify because of its rare but serious complications. GABHS pharyngitis is occasionally accompanied by a diffuse, erythematous, and finely papular rash, frequently described as having a “sandpaper” texture. This condition is known as scarlet fever. The rash often begins around the neck, axilla, and groin and then spreads over the trunk and extremities. Patients with bacterial pharyngitis generally do not have rhinorrhea, cough, or conjunctivitis. Palatal petechiae can be seen in GABHS pharyngitis. They are only 7% sensitive, but are 95% specific.
Differential of Pediatric Fever, Sore Throat, Cough, & RashL Less Likely diagnoses
- epiglottittis
- pertussis
- mono
- retropharyngeal abscess
- viral croup
- allergic rhinitis/pharyngitis
Epiglottitis
Patients with epiglottitis usually appear ill and have a high fever (> 103 F).
They have symptoms of inspiratory stridor, “hot potato” (muffled) voice, dysphagia, and drooling.
Classically patients will be seated in a “tripod” position.
Epiglottitis has a rapid onset and usually presents in patients between 1 and 6 years of age.
The incidence of epiglottitis has decreased significantly due to widespread immunization against Haemophilus influenzae type B , but should be considered in children with any of these symptoms due to its potentially lethal nature.
Pertussis
The initial symptoms of pertussis are nonspecific, similar to those of the “common cold,” and include runny nose, low-grade fever, and mild cough, making the diagnosis in the early stages difficult.
However, symptoms from the common cold typically peak by day three, then slowly resolve and are gone by day seven to ten
The diagnosis of pertussis is considered when the cough has worsened and has been present for at least 14 days..
Mononucleosis
The classic presentation of infectious mononucleosis in children and young adults consists of the triad of fever, pharyngitis, and lymphadenopathy.
Posterior cervical lymphadenopathy is common and specific for mononucleosis.
Palatal petechiae on the posterior oropharynx distinguishes infectious mononucleosis from other causes of viral pharyngitis. However palatal petechiae can be seen in GABHS pharyngitis, so does not help in distinguishing infectious mononucleosis from that condition.
Hepatosplenomegaly also may be present.
Suspicion for this diagnosis usually occurs after a negative rapid strep or throat culture in a patient who is ill for more than 7-10 days.
The monospot test will not become positive until at least 7 days into the illness.
Common causes of infectious mononucleosis are Epstein-Barr Virus or Cytomegalovirus.
Early in the course of mononucleosis, patients may present with a maculopapular generalized rash. The rash is faint, rapidly disappears, and is nonpruritic. Note that if patients with mononucleosis are misdiagnosed with strep and treated with amoxicillin or ampicillin, 90 percent will develop a classic prolonged, pruritic, maculopapular rash.
