CH20 primary care of well and sick infant, child, teen Flashcards
neonate
0-28 days
infancy
1st year
toddler
1-2 yrs old
preschool
3-4 years
school age
5-12 yrs
purpose of well child visit
health promotion (nutrition, safety, immunization)
-tracking growth and development (learning, social)
- parent/provider concerns (diet, sleep, dev)
how often do kids need well child visits?
- NO - best vision range 8 -12 inches or how far mom’s face from baby’s face when bby on nipple
- YES - blueish scleral tint normal first few months (if persists.. consider osteogenesis imperfect)
- yes - bright light can trigger the startle reflex
- yes - blink reflex
term pregnancy in weeks
37 weeks (lungs are mature now) - 41 weeks + 6 days
in 2 week old
A correct.
B: high pitch betterr
C: will react
D: well developed sense of smell (thats why holding a baby is important bc it’ll imprint who holds them and is more comfortable with familiar smell)
“Ag”= always growing
-mom has hep B
-D! without intervention, 40% of HBV exposed newborns develop chronic HBV
persistent neonatal reflexes causes..
need further eval!!
walking reflex
walking motion made with legs and feet when held upright
appears for first 3-4 months, then reappears 12-24 months
rooting reflex
turning head and sucking when cheek stroked
no longer seen by 4 months
moro reflex
aka startle reflex
Throwing out arms and legs followed by pulling them
back to the body following a sudden movement or loud noise.
-no longer seen by 6 months
palmar grasp
-Grasping of an object when placed in the palm
-No longer seen by 7 months
babinski reflex
Stroking the sole of the foot elicits fanning of the
toes.
No longer seen by 6 months.
(adults don’t do this)
best time = earliest u can detect a problem
A! test before baby goes home.
for D, AOM has weeks/ mo of fluid in middle ear so screening will be abnormal (test will not influence treatment plan)
B. face up!
NO soft bumper, nothing in the crib! no positional wedges
“back to sleep, tummy to play”
SIDS
sudden infant death syndrome
need supervised awake “tummy time” to minimize development of positional plagiocephaly
when should tummy time start?
-start asap post birth, building up slowly for a total of 30 mins per day until such time as child easily turns tummy-to-back, back-totummy without assistance, usually by around age 6 months.
ALWAYS SUPERVISE TUMMY TIME!
SIDS recommendations
Back to sleep for every sleep
* firm sleep surface.
* Room-sharing without bed-sharing for the first 6 months is recommended, ideally for 1 year.
* NO soft objects and loose bedding in crib.
* Do not let child fall asleep on nursing pillows or pillow-like lounging pads.
* Never place baby to sleep on a couch, sofa, or armchair.
* Swaddling the baby is fine.
* Pregnant women should receive regular prenatal care.
* Avoid smoke exposure during pregnancy and after birth.
* Avoid alcohol and intoxicating drug use during pregnancy and after birth.
* Breastfeeding is recommended.
* pacifier at nap time and bedtime to reduce SIDS
* Avoid infant overheating.
* Do not use home cardiorespiratory monitors as a strategy for reducing the risk of SIDS.
* Expand the national campaign to reduce the risk of SIDS to include a major focus on the
safe sleep environment and ways to reduce the risk of all sleep-related infant deaths,
including SIDS, suffocation, and other accidental deaths; pediatricians, family physicians,
and other primary care providers should actively participate in this campaign.
stomach size of first 30 days of life (DOL)
cherry to unshelled walnut by day 1
day 7: apricot
day 30: large egg
in womb, only liquid that they can hold and stomach gradually learns to fill and empty
when can u start introducing foods to infants?
no food sooner than 4 months, continue breast feeding
must be exclusively BF for 1st 6 months and continue for 1 year or longer (or infant formula)
feeding frequencies for
neonate
2 months
4 months
6 months
breastfeeding basics
NO clicking (latch isn’t adequate)
D! should be back up by 2 weeks
BF babies make lots of small stools a day (normal) but infant with formula has firmer stools
C ! something is going well if bb has good weight gain.
No Fluroide supplements for the 1st 6 months of life!
D
Pump and dump is rarely the answer
alcohol can pass the blood brain barrier so it can def get into the breast milk
good latch has
no clicking sound, bbys checks are round and no dimples
D!
physiologic jaundice is BEYOND 12 hours of life
hyperbilirubinemia in the newborn
immature intestinal tract can’t reduce bilirubin to urobilirubin for excretion
bilirubin types
- direct (conjugated) bilirubin: Hemolyzed RBC ABLE to be excreted;
elevated because: Sepsis, intrauterine infection, severe hemolytic
disease, biliary atresia, giant cell hepatitis, cystic fibrosis,
galactosemia, alpha-antitrypsin deficiency - indirect (unconjugated) bilirubin: Hemolyzed RBC NOT able to be
excreted; bc of positive Coombs test (Blood groups Rh,
ABO incompatibility)
onset of jaundice less than 24 hours of life…
PATHOLOGIC jaundice (less common)
- metabolic disorders
- hemolytic disorders
- sepsis
- others
risk factors for pathologic jaundice
Underlying illness
Delayed initiation of breastfeeding
Insufficient frequency and ingestion of breastmilk
Giving water before or in addition to breastfeeding
Delayed meconium elimination
Pathologic jaundice intervention
treat underlying illness (if present)
-adequatte fluid intake
-phototherapy if total serum bilirubin > 25 mg/dL
jaundice that occurs 24 hrs to 2 weeks..
PHYSIOLOGIC JAUNDICE (no liver disease; more common)
-within 4-5 day of life
- breast milk jaundice (usul after 1 week)
where does jaundice in the newborn usually start?
starts in face and then makes its way down to body
risk factors for physiologic jaundice
breastfeeding (can inhibit bilirubin excretion)
>10% weight loss
insuff freq or ingesting of BM
genetics
early hospital discharge
physiologic jaundice intervention
-hydrate/intake
-phototherapy if total bili > 25 mg/dL
galactorrhea
breast milk production when NOT lactating
-found in 5% of all healthy NBs REGARDLESS of gender
-DON’T remove the milk from breast bc it’ll stimulate more. body will naturally get rid of it
came on day 10 of life so wont be from chemoprophylaxis that was given day 0 of life
chemosis: conjunctival edema
answer: B: sx’s come 5-14 days post exposure, chemosis common. prevention with maternal C trachomatis screening
-NB prophylaxis prevents GC but NOT chlamydial conjunct
common to see baby breast engorgement onset day 3-4 day of life to 2 week with galactorrhea
and will resolve within 2 months of life
answer:D
gonococcal conjunctivitis in NB
incubation period after exposure 2-7 days
ocular chemoprophylaxis at birth with erythromycin ophthalmic ointment or silver nitrate minimizes risk
neonatal adenovirus infection
causative org of viral conjunctivitis
EXCESSIVE tearing, mildly red conjuntiva
URI symptoms (cough, red throat etc)
chlamydial conjunctivitis treatment in NB
confirm with culture
tx: ORAL erythromycin x 2 weeks d/t pneumonia risk
if eyes are contaminated then respiratory tract is contaminated
at 2 months old…
fall prevention education
at 4 months…
at 6 months
-rolling from tummy to back (supervised tummy time is not really needed anymore)
at 6-8 months of age
baby recognized body as 1 whole
by 12 months/1 year…
stands tall and walk on 2 legs
varies - 12-16 months in other ethnicities
by 18 months
can name single word objects
say no a lot “like an 18 year old”
acts like an 18 year old by copying words like adults do
by 2 years old..
follows 2 step commands (pick up a spoon and give it to me)
can walk up to 2nd floor (with help)
builds a 2 block tower with ease
by 3 years old..
tricycle..3 wheels 3 years
by 4 years old..
D
separation anxiety starts 7-8 months
when do you expect to see lower and upper central incisors in a baby?
lower: 6-10 months
upper: 8-12 months
get concern at age 1 and had NO teeth at all.
C
starting to pull to stand is a good sign
developmental red flags in the young child
PERSISTENCE PRESCENCE of 1 or more of these warrants further evaluation:
by 6 mo: no big smiles or other warm, joyful expressions
by 9 mo: no back and forth sharing of sounds, smiles or other facial expressions
by 12 mo: no response to name, no babbling or baby talk, and/or no back and forth gestures (pointing, showing, reaching, or waving)
by 24 mo: no meaningful 2 word phrases that don’t involve imitating or repeating
C. 18-24months; formal screening earlier without red flags but can miss a sign and then another one at 18-24 for early detection and early intervention
DSM 5 autism spectrum disorder (ASD)
2 core domains:
- deficits in social-emotional behaviors, nonverbal communication behaviors, developing/maintaining/understanding relationships
restricted, repetitive patterns of behavior, interests, or activities with 2 or more present:
- stereotyped or repetitive motor movements, use of objects or speech
-insistance on sameness, inflexible adherence to routines or ritualized patterns of verbal or non verbal behavior
-highly restricted, fixated interested that are abnormal in intensity or focus
-hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of environment
sx sig impair social, job, other areas of function
C
ADHD 3 subtypes
inattentive
hyperactive/impulsive
combined
ADHD diagnosis
-sx must present before 12 yrs old
-sx must be present in at least 2 settings (home and school)
-functional interference: social, academic, extracurricular
inattentive: 5 or more, happen often:
-Fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities
Difficulty sustaining attention in tasks or play activities
Does not listen when spoken to directly
Does not follow through on instructions and fails to finish schoolwork, chores or duties
Difficulty organizing tasks and activities
Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
Loses things necessary for tasks
Easily distracted by extraneous stimuli
Forgetful in daily activities
hyperactivity-impulsivity: 5 or more often:
- Fidgets with hands or feet or squirms in seat
Leaves seat in classroom or in other situations in which remaining seated is
expected
Runs about or climbs excessively in situations when inappropriate
– Can be subjective feelings of restlessness in adults or adolescents
Difficulty playing or engaging in leisure activities quietly
Acts “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers before questions have been completed
Difficulty waiting turn
Interrupts or intrudes on others
when 1st molars come out or at 1 years old
if a baby is born BEFORE 40 weeks gestation and you want to perform a developmental exam, you must correct for…___
do this until?
correct for a preterm! 40 weeks - the gestation.
the gestation - current age = assess as this age
DO THIS UNTIL BABY IS 2 YEARS OLD!
40 weeks - 32 weeks = 8 weeks early/ 2 months
6 months - 2 months = 4 months
assess baby as a 4 month old baby
B! reaches “4” a toy
but in a TERM infant, it responds to its name in 6 months. if reaches for 1 hand and recognizes familiar ppl (4-6 months), babbling mamama and transfer objects hand to hand (4-6 mo), ah and oh sounds and tummy side to side is 6-8 mo
D. up until thomas is 2 years old, we’ll pull back 2 months on his developmental assessment. if he’s not walking by 12 months, bc it means he’s only at 10 months of age.
what makes the difference if kid “catches up” if they are preterm or not?
depends on neonates health at the time at birth
if he was born with mom with sever preeclampsia and got early labor, mom is ill but thomas wasn’t. baby was fine and will catch up
but if thomas had an intrauterine probably and mom is well. and preg was preterm and ended up early but take a little more time to catch up
club foot - foot turned inward with bottom facing sideways
dx at birth or prenatal ultrasound
tx: ponseti method
syndactyly - fusion of 2 or more digits (webbing of skin or bone)
tx: surgery (skin graft)
metatarsus adductus (pigeon toed)
common TRANSIENT/normal issue in new walkers
2-3 months of walking (self resolves)
-passive maniupation to check for flexible or non flexible metatarsus
tx: if persists longer than 4 mo of age, can refer to peds ortho
depends on severity, observation, stretching, passive manipulation, casting, straight last shoes, surgery
polydactyly - extra digit (hand or foot)
tx: surgery at 9-12 mo
B: lots of foreskin before 3 years old and when they grow, it’ll be easily retractable.. and make sure urine is out fine (but if it balloons out then it’s too tight)
D. hydrocele
goes away after 1 years old
non communicating hydrocele
most common
-no connection b/t abdominal cavity and sac around scrotum = fluid filled, transillluminates
non communicating hydrocele presentation and management
fluid filled scrotal sac
transilluminates, non tender, testes NORMAL
-no change in scrotal size, with position change, same at bedtime and on awakening
resolves by age 2 w/o intervention. only refer if size interferes comfort and activity
Reassurance, no risk of herniation; no special skin are needed
communicating hydrocele
(uncommon)
- Incomplete sealing of peritoneal cavity at inguinal area during gestation, leaving communication between abdominal cavity and scrotum
communicating hydrocele presentation and management
Fluid-filled scrotal sac; transilluminates,
nontender; testes normal;
***amount of fluid in scrotum (scrotal size) VARIES with position of
neonate; larger with dependent upright position (day) and smaller
after lying flat upon awakening
risk for abd herniation
refer for ped urologist or surgeon!
Which of the following is most consistent with pyloric stenosis (upper GI obstruction [PS]) or intussusception (lower GI obstruction [I]) or both?
_____ A. Significantly more common in males
_____ B. Sudden-onset, colicky, severe, and intermittent abdominal pain, often with
knees drawn to chest during most intense discomfort
_____ C. Accompanied by loose stools that are often described as currant jelly
appearance (mixture of blood and sloughed mucous)
_____ D. Most common time for symptom onset= Approximately age 3 weeks
_____ E. Post-fed projectile vomiting is present, with the baby eager to eat again
immediately post emesis.
_____ F. Accompanied by a sausage-shaped abdominal mass
_____ G. Olive-shaped RUQ abdominal mass occasionally noted
_____ H. Usually occurs between ages 6‒12 months
_____ I. Ultrasonography is usually first-line diagnostic study.
upper GI is pyloric stenosis, lower GI is intussusception
A. both
B: intussusception (ischiemic bowel)
C: intussusception
D: pyloric stenosis - usually only during 1st MONTH of life. if past that, most likely will not get it
E: pyloric stenosis (1st born male about 3 wks of age thriving until 24 hrs ago and now vomiting projectile and now starving)
F: intussusception
G: pyloric stenosis
H: intussusception
I: both (thinner abd wall/fat pad)
for pyloric stenosis and intusscusception..
send to ER to rehydrate and ultrasound
refer out
pyloric stenosis sx’s
Nonbilious vomiting (often projectile) or regurgitation;
dehydration and malnutrition; jaundice
-“olived” shaped mass in RUQ
- usu at ~3 weeks of life
pyloric stenosis diagnostics & intervention
ultrasound - thickened pyloric muscle
surgery
normal reflux.. intervention?
spitting up to 1 or 2 mouthfuls of breastmilk or formula soon after feeding without effort, coughing, gagging, wheezing, or vomiting
no intervention if normal weight gain
resolves within 12 - 14 months
intussusception patho
telescoping of intestines into the adjoining intsetinal lumen causing bowel obstruction.
if left untx, can be fatal in 2-5 days
intussusception sx’s
vomiting
abdominal pain with knees drawn to chest during worst comfort
rectal passing of blood and mucus
lethargy
palpable abdominal mass
usu comes after a URI
intussusception diagnostics and intervention
ultrasound - pseudokidney signs
gold standard: contrast/barium enema
tx: hydrostatic or pneumatic enemas, surgical reduction if enemas work or perforation noted
B. normal reflux; baby is not in distress
Lower esoph schincter is immature and can spit up. doesn’t cry and gaining weight is good and not worrisome
NO PPI’s not recommended for GERD
b. 14 months
peds immunization
(T/F) MMR should not be given to a 12-month-old whose mother is pregnant. FALSE
(T/F) A 6-month-old who is taking amoxicillin for acute otitis media (AOM) should
have immunizations delayed until the antimicrobial course is completed. FALSE
-delay vaccines with moderate/severe illness with or w/o fever
(T/F) Preterm infants are usually immunized at the schedule that corresponds with
their birth or extrauterine age. TRUE
(T/F) One of the best ways to protect infants younger than 6 months of age from
influenza is to make sure members of their household and their caregivers are
vaccinated against the disease. TRUE
(T/F) Pregnant women should receive inactivated influenza vaccine to protect both
mother and unborn child. TRUE
(T/F) The risk of autism can be reduced through the use of an early childhood
vaccination schedule that minimizes the number of immunizations given at a single visit. FALSE
(T/F) In order to avoid post-vaccine discomfort, younger children should be given a
weight- and age-appropriate dose of an antipyretic, such as acetaminophen or
ibuprofen, prior to receiving immunizations. FALSE
(T/F) Children 6–11 months of age who are traveling outside the United States
should receive 1 dose of MMR. TRUE
df
(Y/N) A 28-year-old woman who is 29-weeks pregnant and received Tdap
approximately 3 years ago YES - shes protected bc shes up to date but want to boost with another one to pass it across the placenta
(Y/N) The spouse of a woman in the 2nd trimester of pregnancy who provides
documentation of receiving Tdap 2 years ago NO bc it’s recent- need everyone around baby to be up to date
(Y/N) A 70-year-old man who received a Td about 8 years ago, slated to be one of his son’s newborn’s caregivers YES - need pertussis up again if he’s going to be near their son
most common type of anemia in childhood?
iron deficiency anemia
-microcytic, hypochromic, elevated RDW
Iron def most common reason? a child 12 months and older most potent risk factor? < 9 months?
depletion of birth iron stores (usu lasts until ~6 months of age), or starting of lower iron diet in later infancy, early toddler stage
child 12 or older, drinking excess cows milk of 16 oz per day
< 9 months most potent risk factor is maternal iron depletion and prematurity
when do you start iron fortified formula or iron enriched foods?
most common for IDA in age 12-30 months.
Most calories in first year of life should be from breast milk with iron supplementation starting at ages 4–6 months, depending on amount of iron-fortified formula intake or iron-enriched foods.
C. at risk age of 16 months and diet of only whole milk
E: at risk age of 6 months and premature (didn’t absorb enough of mother’s iron stores)
iron def screening in young children
universal screening for IDA via hemoglobin at 12 months old then selective screening at any age in children at increased risk for iron deficiency with:
-Hb < 10, get ferritin to confirm iron def
-with milder anemia (hb 10-11), alt eval plan includes treating with iron for 1 month. if Hb rise of 1 or more after 1 month of iron therapy helps confirm iron def
prevention of preterm infants on Iron def
give breast milk and 2 mg/kg/d of elemental iron supplements or foods by age 1 month until 12 months
if using formula, iron supps could be required
prevention of term infants on iron def
if term infant taking more than 1/2 feedings as human milk, need 1 mg/kg/d iron supp starting age 4 months until giving iron foods
Toddlers can receive adequate iron through heme sources of iron (red meat), nonheme sources (legumes, cereal), select vegetables such as dark, leafy greens, and vitamin C-containing foods to promote iron absorption.
tx for IDA infant, child, adult with established IDA
supp iron x 2 months after correction of anemia
ongoing eval for IDA in young child
C. majority of kids are vit D def!
B. hydration is key throughout the life span!
micronutrient requirements for children
-calcium: 500-1300 mg depends on age (milk, collards, peas, tofu, cottage cheese, 1% milk, soy milk, almonds)
-vitamin D: 400 IU daily (1L infant form or vit D fort cows milk with 400 IU) sun exposure’s contribution to vit D depends on residence, skin tone, sunscreen, clothing etc
In any patient with an injury, assess to see
if the history of the causative event matches with the clinical presentation.
2nd degree burn and NOT consistent with history
C. significant BSA in this child and genital burns are tx with speciality care no matter what age or degree
D. horrific injury (even if moms admits it was an accident, you still notify bc want to know child is safe)
child maltreatment risk factors
Child <4 years of age
Special needs that can increase caregiver burden (disabilities, mental or physical health problems)
Parents’ lack of understanding of child’s needs, lack of parenting skills and knowledge of child development, overestimating child’s cognitive ability
Parental history of child maltreatment
Substance abuse/mental health issues in family
Parental characteristics (e.g., low education, low income)
Nonbiological, transient caregivers in the home (e.g., mother’s male partner)
Family social isolation, disorganization, violence
Parenting stress, poor parent-child relationships
Community violence
Concentrated neighborhood disadvantage (e.g., residential instability, high unemployment rates)
what is the first and second most common reason for ped sick visits?
- viral URI
- acute otitis media AOM in ages 6 mo -2 years old
organisms in acute bacgerial otitis media
S pneumonia 50% - low rate resolve w/o antix
H influenzae 29 % - mod rate resolve
M catarrhalis 28% - nearly all resolve w/o antibx
acute otitis media diagnosis in children
-moderate or severe bulging of tympanic membrane OR new onset otorrhea not related to otitis external with otalgia (ear pain) NEED EAR PAIN!
-mild bulging of TM AND recent (48 hrs onset o r less) onset of ear pain (tugging, holding, rubbing) OR intense TM erythema with otalgia
acute otitis media management
- analgesics (tylenol or advil) if have pain
- watchful waiting if otherwise well child (not head or neck alternation or immunocompromised) 6 months or older with non severe illness based on joint decision making with parents/caregivers for unilateral AOM. if fails to improve or worsens, start antib in 2-3 days
**nonsevere AOM vs severe AOM
Nonsevere illness:
-Mild otalgia for < 48 hours
Or
-Fever < 39°C (102.2°F) in the past 24 hours
Severe illness:
-Moderate-to-severe otalgia
Or
-Otalgia for >48 hours
Or
- Fever ≥ 39°C (102.2°F)
give antib for AOM if
- younger than 6 months old (non severe or severe, uni or bi ears doesn’t matter)
- Severe illness with unilateral or bilateral AOM in children ≥ 6 months
- non severe BILATERAL AOM in young children (6–23 months)
normal TM
cone of light bony landmark, transluscen with air behind
AOM
bulging, bright red, bone landmarks gone trapped behind fluid behind middle ear
“pus in small trapped space”
AOM bullous myringitis
bulla - blistering of TM and can rupture and have blood in ear canal
AOM retracted TM
otitis media with effusion
no inflammation but fluid behind
AOM antib length of time for < 2 year olds, 2-6 years, 6 and older?
<2 years=10 days
2–6 years=7 days
≥6 years=5–7 days
1st line for AOM antib
Amoxicillin (80–90 mg/kg/d PO in 2
divided doses)
Or
Amoxicillin-clavulanate (90 mg/kg/d
PO of amoxicillin, with 6.4 mg/kg/d of
clavulanate in 2 divided doses)
with PCN allergy: (stay away from 1st generation cephalosporins)
Cefdinir (14 mg/kg/d PO in 1 or 2 doses)
Or
Cefuroxime (30 mg/kg/d PO in 2 divided
doses)
Or
Cefpodoxime (10 mg/kg/d PO in 2 divided
doses)
Or
Ceftriaxone (50 mg/kg IM or IV/day for 1 or 3 d,
no more than 1 g/d)
antib tx after 48 -72 hrs with failure of initial antib treatment
Amoxicillin-clavulanate
Or
Ceftriaxone (50 mg/kg IM/IV for 3 d, no
more than 1 g/d)
if PCN allergy:
ceftriaxone x 3 days (shots)
or
Clindamycin PO with or without a third-generation
cephalosporin. Consider tympanocentesis, referral to
specialist
otitis media with effusion in children
fluid in ear WITHOUT signs of ear infection (serous otitis)
otitis media with effusion intervention
watchful waiting (75-95% resolve within 3 months w/o tx)
NO antib, antihistamines, decongestants recommended
otitis media with effusion evaluation
consider aduiological eval if lasts > 3 months, if concerns with hearing, speech, language with parents, or 3 months after a prior audiologic eval in a child being observed with OME
if language delay and/or suspected or documented hearing loss = consider surgery!
tympanostomy tubes and/or adenoidectomy
if speech delay, refer speech therapy
what is the most common cause of temporary speech delay in early childhood?
persistent otitis media effusion
*think head under water so hearing is muffled
1: A - age
2. A - severe disease from higher fever and bilateral
3. watchful waiting (non severe)
4. A - > 48 hrs of otalgia
empiric antib for CAP for 5-17 year olds
if think bacterial pneumonia (S pn, H influ, M cat): amoxicillin or augmentin
(add macrolide if 5 yrs or older)
if think atypical (C pn, M pn, L pneu): azithromycin or clarithormycin
if influ penumonia; oseltamivir
small saliva, cracked lips, “thirsty”
B. moderately dehydrated
and has peed so a good sign
- The NP suspects Taylor has gastroenteritis. An appropriate treatment option to
prevent further dehydration is a single oral dose of:
A. An antidiarrheal agent (e.g., bismuth salicylate [Pepto Bismol®]).
B. An antimotility agent (e.g., loperamide [Imodium®]).
C. A 5-HT3 antagonist (e.g., ondansetron [Zofran®]).
D. Antiparasitic antimicrobial (e.g., metronidazole [Flagyl®])
- You provide the following information to Taylor’s father.
A. Taylor can go home now on rehydration therapy with an appropriate oral
rehydration solution and clear liquids.
B. Taylor should be started on rehydration therapy with an appropriate oral
rehydration solution in the office now with a goal of demonstrating ability to
tolerate oral fluids.
C. Given Taylor’s hydration status, he should be hospitalized for parenteral fluid
replacement.
D. Taylor is able to go home on a diet of dry toast, mashed bananas, applesauce,
and white rice along with sips of clear liquids.
- C: 5 HT3 antagonist (ondansetron Zofran)
most are viral in gastroenteritis. don’t want to give an antimotility and want virus OUT
avoid salicylate antidiarrheal in viral illnesses
2: B
none to minimal dehydration: rehydration therapy?
NO
sips of fluid as tolerated
mild to moderate dehydration: rehydration therapy?
oral rehydration with ORS 50-100 mL/kg over 3-4 hours in office or urgent care (just as good as IV)
Zofran if needed
<10 kg: 60–120 mL oral rehydration
solution (ORS) for each loss; >10 kg: 120–240 mL for each loss
severe dehydration: rehydration therapy?
lactated ringer solution preferred over normal saline IVF
boluses 20 mL/kg until improvement (perfusion, LOC) then 100 mL/kg over 4 hrs
Zofran if needed
<10 kg: 60–120 mL oral rehydration
solution (ORS) for each loss; >10 kg: 120–
240 mL for each loss
if can’t drink, give NG tube or D5W1/4 NS with K 20 mEq IV
MILD hydration status assessment
3-5%
-slightly dry lips, thick saliva
-tears present
-normal turgor, fontanels, cap refill (<1.5 s), mental status
-UO slightly decreased
-thirst:normal to slightly increased
MODERATE hydration status assessment
6-9%
- turgor: recoil < 2 secs
- fontanels: slightly depressed
-dry lips, oral mucosa
eyes slightly sunkened, dec tears
- cap refill 1.5-3 s
- fatigued, restless, irritable
decreased UO
- mod inc thirst
SEVERE hydration status assessment
> 10%
- turgor: recoil > 2 secs
- fontanels: depressed
- very dry lips, oral mucosa
- deeply sunken, tears
absent
- cap refill > 3 seconds
- Apathetic, lethargic,
unconscious
- Minimal UO
- Very thirsty or too
lethargic to assess
scarlet fever presentation
Agent: BACTERIAL
S. pyogenes (group A betahemolytic streptococci)
timing: **sore throat and rash THEN fever and adenopathy
Sandpaper-like RASH
beefy red tongue/strawberry
exudative pharyngitis
fever,
headache,
tender, localized anterior cervical lymphadenopathy
- Rash erupts on day 2 of
pharyngitis and often peels a
few days later.
scarlet fever treatment
1st line: penicillin (PO or IM) or oral amoxicillin
PCN allergy: oral macrolide
(azithro-, clarithro-, erythromycin)
roseola presentation
Agent: Human herpes virus-6 (HHV-6)
usu in 6mo-24 months year olds
**HIGH fever for 3-6 days then Rosy-pink macular or maculopapular rash lasting hours to 3 days
supportive treatment
-90% are < 2 years old
febrile seizures in 10% children affected
rubella presentation
**3 day measles/German Measles (EVERYTHING HAPPENS AT ONCE)
-fever, sore throat, malaise, nasal discharge
diffuse maculopapular rash lasting ~ 3 days
-Posterior cervical and postauricular lymphadenopathy beginning
5–10 days prior to onset and present during rash
- Arthralgia in about 25%
(most common in women)
rubella intervention
mild, self limiting illness
TERATOGENIC! 1st trimster EXPOSURE is greatest risk = vaccine preventable disease = Congenital rubella syndrome
dz transmittable for ~1 week prior to onset of rash to ~2 weeks after rash appears
get rubella IgM (M= miserabblleeee)
Measles/Rubeola presentation
agent: rubeola virus
10 days measles
Fever + 3 C’s: coryza (running nose), cojunctivitis, cough
generalized lymphadenopathy
-photophobia
THEN after day 3-4 = maculopapular rash
-*Koplik spots (~2 days prior to onset of rash as white spots with blue rings held within red spots in oral mucosa) rules IN (but not always present)
-Mild Pharyngitis; NO exudate
after onset of symptoms, may coalesce to generalized erythema.
Measles management
vaccine preventable!
- dz transmitted w/in 1 week before rash onset to 2-3 wks after
- CNS and respiratory tract complications common
supportive treatment
-lab confirmation presence of serum rubeola IgM
infectious mononucleosis (IM) presentation
agent: epstein barr virus (human herpes virus 4)
Maculopapular rash in ~20%, rare petechial rash
- Fever, “shaggy” purple-white exudative pharyngitis (STINKY), malaise,
- marked diffuse lymphadenopathy
- hepatic and splenic tenderness with occasional enlargement
infectious monoucleosis diagnostics
Diagnostic testing: Heterophil antibody test (Monospot®),
leukopenia with lymphocytosis and
atypical lymphocytes
infectious monoucleosis intervention
> 90% develop rash if given amoxicillin or ampicillin during illness
-respiratory distress potential with enlarged tonsilss/lymphoid tissue = impinge upper airway = corticosteroids help
-splenomegaly on day 6 and 21 onset
-NO contact sports for ≥1 month due to risk of
splenic rupture.
hand, foot, mouth disease agent
coxackie virus A16
hand, foot, mouth disease presentation and duration of illness
-fever, malaise, sore mouth,
anorexia then 1–2 days later, lesions appear (mouth, hand, sole of foot = refuse to walk);
-conjunctivitis
-pharyngitis
Duration of illness: 2–7 days
hand, foot, mouth disease management
Supportive treatment, analgesics important
fecal-oral transmission or droplet = highly contagious! 2-6 wk incubation
Fifth disease agent
human parvovirus B19
fifth disease presentation
-3–4 days of mild, flu-like illness then 7–10 days of red rash
-begins on face with “slapped cheek” appearance then spreads to trunk
and extremities.
-contagious before rash
fifth disease risks, dx, and management
-droplet transmission
-leukopenia common
-Risk of hydrops fetalis causing pregnancy loss
-if want to confirm dx (not needed if most likely), get parvovirus B19 IgM lab testing or Parvovirus B19 viral load testing
-Supportive treatment.
If pregnant = get consultation bc complications/loss
kawasaki disease presentation
For acute-phase illness (~11 days), fever ≥104°F (40°C) lasting ≥5 days, polymorphic exanthem on trunk, flexor regions,
and perineum
-strawberry tongue with extensively chapped lips
- bilateral conjunctivitis, usually without eye
discharge
-cervical lymphadenopathy
- edema and erythema of the hands and feet with
peeling skin (late finding, usually 1–2
weeks after onset of fever)
-no other illness accountable for the findings
kawasaki disease management
- agent unknown
Usually in children ages 1–8 years
-Treatment with IV immunoglobulin and PO aspirin during the acute phase = reduction in rate of coronary abnormalities, such as coronary artery dilation and coronary aneurysm. - Requires expert consultation and treatment advice about accurate
diagnosis, aspirin use and ongoing monitoring warranted, usually at a tertiary pediatric medical center.
multisystem diseases are usually viral or bacteria?
almost always viral
- Tina is an otherwise well 5-year-old who presents with her mother. They report that Tina has had a one-day history of “sore throat and swollen glands” as well as a low-grade fever and rash. Examination reveals a diffuse maculopapular rash, mildly tender posterior cervical and postauricular lymphadenopathy, and pharyngeal erythema without exudate. The remainder of her history and review of systems is unremarkable. Per her mother’s report, Tina has not received any immunizations since age 6 months. The most likely diagnosis is:
A. Scarlet fever.
B. Roseola.
C. Rubella.
D. Rubeola.
look at TIMING and risk factor!
Sammy is an 18-month-old who presents with a 4-day history of high fever that reached 103.2°F (39.6°C). A rosy-pink maculopapular rash developed this
morning. The most likely diagnosis is:
A. Rubeola.
B. Roseola.
C. Scarlet fever.
D. Rubella.
FEVER then rash = roseola
Jannetta is a 16-year-old who presents with a 3-day history of pharyngitis and fatigue. Findings include exudative pharyngitis, minimally tender anterior and posterior cervical lymphadenopathy, and right and left upper quadrant abdominal tenderness. Per Jannetta’s record, she is up-to-date with all recommended vaccinations. This is most consistent with:
A. S. pyogenes pharyngitis.
B. Infectious mononucleosis.
C. Hodgkin disease.
D. Gonococcal pharyngitis
answer B:
anterior cerivcal can cause a sore throat but posterior cervical lymph can NOT cause sore throat so it means the lymthadneapthy is diffuse affecting multiple nodes, RUQ tenderness (liver), LUQ (stomach/spleen) = multisystem illness = usu viral!
B.
Hodgkins would not cause throat findings
gonococcal pharyngitis would not cause the other findings except pharyngitis
if questions say they aren’t or are up to date with vaccines, think
if up to date, don’t think the answer is r/t to vaccine disease
if not up to date (ie MMR, think ones that would have been prevented)
competitive sports and infective mononucleosis
avoid contact sports for 1 or more month due to splenic rupture
infectious mono can have what other common complaints dx at same time
acute otitis media bila/unilateral
Jared is a 17-year-old with no known medication allergy who has suspected
infectious mononucleosis. He is febrile and complains of acute otalgia on the left for the past three days. Physical examination reveals a left tympanic membranethat is red and bulging. When considering therapy for Jared, which of the
following should not be prescribed?
A. Acetaminophen
B. Ibuprofen
C. Amoxicillin
D. Azithromycin
C. Amoxicillin - if have mono and given amoxicillin, will break out in rash !!
- Timmy is a 4-year-old boy who presents with his mother today for a sick visit. For the past 8 days, he has had intermittent fever as high as 104.5°F (40.3°C) and
has complained of a sore throat and increased throat pain with swallowing, but without difficulty taking fluids. He has little appetite, but his mother denies
nausea, vomiting, diarrhea, or constipation. On examination, you note he is alert, appears ill without acute distress, and has extensive cervical lymphadenopathy,
injected conjunctiva, oral erythema, and a peeling rash on his hands. You
consider a diagnosis of:
A. Infectious mononucleosis.
B. Fifth’s disease.
C. Hand, foot, and mouth disease.
D. Kawasaki disease.
answer: D
multisystem illness; don’t hear any congestion or respiratory systems; remained febrile for many days
younger child in males
if a neonate (<28 days old) is febrile, what should you do?
-treat with empiric parental antimicrobial therapy
-send to hospital for neonatal sepsis eval!!
red flags in ill younger child (≥1 month–3 years)
-pale or cyanotic skin
-poor cap refill (under hydration)
-lethargic, does not age approp resist examine
weak/no cry, esp with examination or inconsolably irritable
-tachypnea (RR ≥50% ULN for age)
-tachycardia, even with adjustment for fever
-unable to take oral fluids, vomiting, dry mucous membranes
-no recent urinary output (w/in 4hours)
reassuring findings in younger child (≥1 month–3 years)
-Warm, dry, appropriately colored to fingertips
-Brisk capillary refill (≤2 sec)
-Regards parental face, clings to parent, consolable,
age-appropriately resists examination, lusty cry,
especially during examination
-Smiling, interactive as appropriate in relationship to
degree of illness
-Respiratory rate <50% above ULN for age
-Heart rate WNL, adjusted for fever
-Tolerating oral fluids without vomiting, adequately wet
diapers
often absent in a seriously ill young child
hypotension, cool skin, and/or nuchal rigidity
T/F In a febrile child, the degree of temperature reduction in response to antipyretic therapy is not predictive of presence or absence of bacteremia.
true
T/F Response to antipyretic medication does not change the likelihood of a febrile child having a serious bacterial infection and should not be used for clinical
decision-making.
True
even if temp goes down with antipyretics, still can be something serious going on so do eval
(T/F) The absence of tachypnea is the most useful clinical finding for ruling out pneumonia in children
true
the young and the old - the presence of tachypnea (esp with cough) would help rule IN and absent rules OUT pneumonia
- You are seeing Benjamin, an 18-month-old, who presents with his mother for a sick visit. His last well-child visit was at age 5 months, when he was up-to-date for recommended immunizations. Mom states that Benjamin has not been seen by another healthcare provider nor received vaccines since his last visit at your practice. He now presents with a 2-day history of crankiness and fever. Benjamin has had a poor appetite for the past 2 days but has not vomited and has been
taking small amount of fluids. His last wet diaper was approximately 2 hours ago. Exam reveals T=39.6°C (103.4°F), P=150 BPM, RR=45/min. Additional findings
include slightly dry mucous membranes, capillary refill of <2 seconds, oropharyngeal redness, bilateral, red, immobile TMs, and a clear chest. The child has a high-pitched cry, is difficult to console, and does not regard his mother’s face. Your next best action is to:
A. Start the child on high-dose PO amoxicillin and oral analgesia with ibuprofen.
B. Give Benjamin an age- and weight-appropriate dose of an oral antipyretic with plans to reassess after 1 hour.
C. Initiate an evaluation for sepsis and consider for inpatient admission.
D. Administer a single dose of IM ceftriaxone and arrange for revisit tomorrow.
Not A bc not JUST tx otitis media. Not B bc doesn’t matter what happens even with antipyretics.
answer: C
clear chest - don’t think pneumonia
*key words are “high pitched cry, difficult to console, and does not regard mothers face** = YES altered/abnormal neuro exam (higher risk for meningitis) due to high pitched cry, difficult to console, doesn’t regard mom’s face
sepsis
presence of pathogenic organisms or their toxins in the blood and tissues with a resulting systemic inflammatory response
sepsis workup regardless of age
-CBC with diff (bacterial or viral shift)
-blood culture (bacteria in blood usu in sepsis)
-UA and urine C&S via catheter or suprapubic tap (in UTI, peylonephritis = WBC, bacteria, urine C&S are positive)
-Lumbar puncture for CSF analysis and culture (pleocytosis (WBC in CSF) and other findings with bacterial and viral meningitis (altered neuro exam)
-chest x-ray (assist for pneumonia dx)
case dependent add on workup:
-if have diarhea get: stool culture, fecal WBC (dx of shigella or infectious diarrhea)
-sepsis markers: Lactate, ESR, CRP, IL-1b, IL-6, IL-8, TNF-alpha, leukotriene
B4, procalcitonin (Can be helpful in identifying severe cases with higher risk of mortality)
stridor is caused by ____, where getting air ___ is the problem than getting air ____, with the characteristic sound heard on _____
Stridor is caused by upper airway obstruction, where getting air IN is more of a problem than getting air out, with the characteristic sound heard on INSPIRATION.
differentials diagnosies of stridor in children
croup (laryngotracheobronchitis)
foreign body
congenital obstruciton
peritonsillar abscess
acute epiglottitis
croup (laryngotracheobronchitis) features and intervention
STRIDOR
viral, allergic (age 6 months - 5 years)
supportive treatment, systemic corticosteroid therapy
foreign body features and intervention
STRIDOR - acute onset from mechanical obstruction (toddlers)
refer to ED for removal
congenital obstruction features and intervention
present from birth
-surgical repair
Peritonsillar abscess features and intervention
SRIDOR - uvula pushed to the other side
-Usually bacterial, older child or adult
- “hot potato” voice, difficulty swallowing, trismus (locked jaw), contralateral uvula deviation
Tx: send to ED! admit in hospital for airway maintanence prompt ENT & possible surgery
acute epiglottitis features and intervention
STRIDOR ,children ages 2–7 years. Abrupt onset of high-grade fever,
sore throat, dysphagia, and drooling
-Bacterial origin (most often H. influenzae type B, potentially preventable with Hib vaccine)
REFER TO ED/inpatient for airway maintenance! Prompt ENT consult and antimicrobial therapy
high riding epiglottis
anatomic variation ! no disease state a/s with it
Wheeze is caused by ____. Where getting air ____ is more of a problem than getting air ___
The characteristic sound starts on ____, can progress as well to ____ with
severe disease.
Wheeze is caused by lower airway obstruction, where getting air out is more of a problem than getting air in.
The characteristic sound starts on expiration, can progress as well to inspiration with
severe disease.
differentials diagnosis is of wheeze in children
acute bronchiolitis
acute bronchitis
asthma
acute bronchiolitis features and intervention
- “disease of the HAPPY wheezer,” fever (consider pneumonia if >102.2F with focal crackles), tachypnea, retractions (grunting, nasal flaring)
- < 2 years old
-most likely RSV, less commonly from influenza or adenovirus
-short-term acute illness with wheezing often persisting ~3 wk. - Most serious in early infancy (<3 months) and preterm infants. = exhausted breathing fast
-occur winter months: November through April
tx: supportive only! (NO evidence broncho, steriods help)
-to prevent RSV,g give palivizumab (Synagis) for premies < 28 wks, chronic lung dz, congenital heart dz, or immune deficiency syndrome)
acute bronchitis features and intervention
-Viral, cough (prod or non prod), dypsnea, low grade fever, h/a, wheezing
cough> 5 days to 2-3 weeks
-Supportive; use inhaled beta2- agonist, oral antiinflammatory
treatment
How to assess asthma control in children (0-5 years olds)
Ask about sx control: in the past 4 weeks (Y/N)
1. Daytime asthma symptoms for more than a few minutes,
more than 1x/week?
2. Any activity limitation due to asthma? (Run/plays less than
other children, tires easily during walks/playing)
3. Reliever medication needed more than 1x/week?
4. Any night wakening or night coughing due to asthma?
Well controlled: 0 positive answers
Partly controlled: 1–2 positive answers
Uncontrolled: 3–4 positive answers
risk factors for asthma exacerbations:
Uncontrolled asthma symptoms
- ≥1 severe exacerbations in previous year
- Start of child’s usual flare-up season (especially if autumn/fall)
- Exposures: Tobacco smoke, indoor and outdoor air pollution, indoor allergens, esp. with viral infection
- Major psychological or socio-economic problems for child or family
- Poor adherence with controller medication, or incorrect inhaler frequency
- Outdoor pollution (NO2 and particles)
stepwise approach for managing asthma in children 0-5 years old
**step 2 is where I will see fall in.
ie: in fall season, pt has asthma only been doing intermittent shot corse of ICS at onset of RTI. get him to start low dose ICS daily@
Step 3 & 4 is with specialty consultation
step UP if needed for asthma when
first check adherence, inhaler technique, alternative dx, and environmental control
assess control by asking those 4 q’s! if not “well controlled / 0 positive answers), step up.
step DOWN if possible if
asthma well controlled for at least 3 months
find lowest treatment that controls both sx/s and exacerbations
don’t completely stop ICS unless needed to confirm asthma dx
How to assess asthma control in children (6-11 years olds)
Ask about sx control:
In the past 4 weeks, has the patient had: (Yes/No)
1. Daytime asthma symptoms more than 2x/week?
2. Any night waking due to asthma?
3. SABA reliever for symptoms more than 2x/week?
4. Any activity limitation due to asthma?
Well controlled: 0 positive answers
Partly controlled: 1–2 positive answers
Uncontrolled: 3–4 positive answers
for children 6-11 year olds, assess risk factors for asthma by:
Assess risk factors at diagnosis and periodically
**Measure FEV1 (start at age 6) :
-at the start of treatment
-again after 3‒6 months of controller treatment to record patient’s personal best lung function
-and then again for periodically for ongoing assessment
Potentially modifiable risk factors for exacerbations in 6-11 year olds:
- Medications: Frequent, high-dose SABA use , inadequate ICS use, not prescribed ICS, poor adherence, incorrect inhaler technique
- Other medical conditions: Obesity, chronic rhinosinusitis, GERD, confirmed food allergy
- Exposures: Smoking, allergen exposure, air pollution
- Context: Major psychological or socioeconomic problems
- Lung function: Low FEV1 (esp. <60% predicted), high bronchodilator reversibility
leukotriene modifiers caution
black box warning of mood destabilizers
Stepwise Approach for Managing Asthma in Children Age 6 to 11 Years
*step 3 - prevent inflammation iwth ICS and LABA for prolonged bronchodilator OR med ICS daily OR MART (ICS and formoterol on daily basis AND reliever therapy along with SABA)
nebulizer vs DPI/MDI
if > 5 years old = MDI/DPI (with spacer) but high rate of incorrect use cus coordination and timing needed
Adam, a 7-year-old boy with a prior diagnosis of asthma, presents with his parents for a well-child visit. He is new to your practice and has not had a healthcare visit in the past year. Adam’s mom mentions that he took a “pill to control his breathing, but we ran out. Right now, he uses the albuterol pump once or twice a day. This keeps his cough under pretty good control. The inhaler works quickly most of the time.” You advise the following:
A. Add a twice-a-day long-acting beta2-agonist as needed to ensure Adam has
better cough control.
B. Low-dose ICS-formoterol should be added to Adam’s treatment regimen.
C. A leukotriene modifier is an acceptable first-line controller medication for Adam.
D. No additional medication is needed as Adam has adequate symptom control with
the current albuterol dose and frequency.
answer: B
-the pill is leukotriene modifier (NOT 1st line med)
daily use of SABA is bad! no contorller med. He’s chasing airway inflammation with a SABA. need to add in ICS-formorterol
Conner is a 6-year-old boy with a history of asthma and presents during an acute exacerbation with cough and shortness of breath. He is able to speak a few words at a time before having to catch his breath. He is without fever and his FEV1 is 70% personal best. He is currently taking a medium-dose ICS via MDI with spacer for controller therapy and SABA PRN. The NP recommends:
A. Switching ICS therapy from MDI to a nebulizer.
B. Adding a LABA to his current regimen.
C. Initiating a short course of oral corticosteroid therapy.
D. Adding theophylline to his current regimen.
answer: C
-don’t want to add more bronchodilators
-theophylline not in child guidelines
