Exam 1 Flashcards
1
Q
Pain: physiologic markers
A
-RR, heart rate, oxygen desaturations
-behavior: grimacing, high-pitched crying
2
Q
how to estimate eGFR in peds
A
Bedside Schwartz: crCl= (o.413 x height) / SCr
3
Q
What are some challenges in pediatric pharmacotherapy?
A
-PK/PD differences (drug selection and dosage)
-psychosocial influence on drug therapy
-caregiver medication administration hesitance
-dosage formulation selections
-off-label medication use
4
Q
Limitations to off-label drug usage
A
-potential for denied insurance provider coverage
-liability for adverse effects
-limited experience in specific conditions or age groups
-limited available dosage formulations
5
Q
for water containing formulations prepared from solid ingredients USP recs:
A
a beyond- use date is no later than 14 days when stored at cold temps (2-8C)
6
Q
reasons for non-adherence in peds
A
-apprehension regarding medication adverse effects
-caregiver inability or unavailability to administer drugs
-caregiver may be overwhelmed/confused
-inappropriate measurements of medication doses
-missed doses due to resistance from the child
7
Q
drug absorption in peds
A
-higher gastric pH early in life (more basic environment exists)
-gastric emptying rates increase dramatically during first week of life = more delivery of intact drug compounds to the site of absorption
OVERALL: effects of reduced gastric emptying and poorly coordinated intestinal contractility = decreased rate of drug absorption
8
Q
rectal drug delivery
A
–> have higher-amplitude pulsatile contractions (expels solid dosage forms)
-may decrease time drug is able to be absorbed (decreases bioavailability)
9
Q
Distribution of drugs
A
-larger total body water –> more intracellular fluid
-infants have less muscle/fat then adults
inc Vd of hydrophilic drugs
dec Vd of lipophilic drugs
10
Q
Protein binding
A
-decreased concentrations of circulating proteins
-decreased binding affinity of fetal albumin
= increased free fraction of drugs
–> risk of displacement of bilirubin from albumin binding sites (kernicterus: albumin deposits in the brain and can cause cell atrophy + neurologic damage)
11
Q
elimination implications for drug dosing
A
-slower clearance (in drug elimination by the kidney)
-longer 1/2 life
-generally, less frequent dosing required (or longer drug intervals)
12
Q
advantage of liquid dosage forms (solutions/suspensions)
A
dose flexibility, easy to swallow
*most commonly preferred in children
13
Q
disadvantage & challenge of liquid dosage forms
A
-lack of controlled release mechanisms, volume required for dose, accuracy in measuring devices
challenge: not all commercially available, single concentrations VS extemporaneous compounded: various available concentrations –> at risk for medication errors
14
Q
Pros and Cons of: chewable tablets
A
P: minimizes need for additional liquid
C: relies on ability to chew, cannot utilize with extended release medications, may not mask taste, may be difficult to control dosage
15
Q
Pros and Cons of: minitablets
A
P: ease the need for swallowing tablets
C: limited dosage flexibility, maximum milligrams per tablet
16
Q
Pros and Cons of: ODTs
A
P: allows for quick dissolving without need for additional liquid
C: cannot easily split (limits dose flexibility), challenge with masking taste
17
Q
Pros and Cons of: orodispersible films
A
P: can offer dose flexibility with strip cutting mechanism
C: hard to mask tase, higher cost to packaging/manufacturing
18
Q
Pros and Cons of: powder packets
A
P: eliminated need for crushing tablets, ready to use manufactured packets
C: may require significant volume to mix, not easily titratable
19
Q
Pros and Cons of: sprinkle capsules/granules
A
P: can ease in the administration with food
C: limited dose flexibility
20
Q
Enteral Formulation Consideration: Palatability
A
-primary source of non-compliance in children
-manipulation can change taste
-mix with food/drink: chocolate syrup, peanut butter, applesauce
21
Q
risk associated with excipients: benzoyl alcohol
A
-can cause neurotoxicity and metabolic acidosis, esp concerning in neonatal population
-used as a preservative to protect from microbial contamination
ex: IV lorazepam
22
Q
risk associated with excipients: ethanol
A
-can cause neurotoxicity
-used as solvent to dissolve/disperse particle into another
ex: dexamethasone intensol solution
23
Q
risk associated with excipients:: polysorbates
A
-can cause liver and kidney failure; thrombocytopenia, ascites, and pulmonary deterioration observed in neonates
-used as a surfactant to increase solubility of one agent with another agent
ex: IV amiodarone
24
Q
risk associated with excipients: propylene glycol
A
-can cause seizures, hyperosmolarity, metabolic acidosis, and neurotoxicity
-used as a solvent
ex: IV phenobarbital
25
risk associated with excipients: sorbitol
-can lead to osmotic diarrhea
-used as a sweetener, to mask taste/increase palpability
ex: loperamide
26
beyond use date for standard non-preserved and preserved aqueous dosage forms
np: 14 days in fridge
p: 35 day in fridge or temp controlled room
27
beyond use date for oral liquids that are nonaqueous
oral liquids: 90 days in fridge or controlled room temp
other non-aqueous: 180 days in fridge or temp controlled room
28
Compounding oral suspensions: things to avoid
-need to avoid formulations with extended-release products
-beware capsules that are hard coated gel caps or contain time-release beads
29
Gestational age (AG)
-from conceptions, "how far along in the pregnancy"
ex: 34 5/7 = from the first day of the mothers last menstrual cycle to the current date is 34 weeks + additional 5 out of next 7 days
30
Post-natal Age (PNA)
-chronological age, time in days/weeks/months since birthday
ex: born on March 1st (today is march 3rd) PNA = 2 days
31
Post-menstrual age (PMA)
-combination of GA + PNA
ex: 34 5/7 + 2 days = PMA = 35 weeks
32
*Age ranges for pediatric dosing: neonate
birth to 30 days
--> if pt is pre-term, PMA/corrected age up to ~44 weeks
33
*Age ranges for pediatric dosing: infant
30 days to 1 year
34
*Age ranges for pediatric dosing: child
1 year to 12 years old
35
*Age ranges for pediatric dosing: adolescent
12 years to 18 years old
36
*weight conversion= lbs to kg
1 kg = 2.2 lbs
37
*height conversion inches to cm
1 inch = 2.54 cm
38
Body surface area equation (BSA)
m^2 = sqt root (height cm * weight kg) / 3600
39
*drug monograph: dosing section
-recommendations stratified by age, weight etc
-take note of max mg/dose or mg/day recs
-identify the correct indication for use
-be sure you are looking at the right ROUTE
40
*drug monograph: preparations for admin (peds)
-provides information such as concentrations and appropriate diluents for reconstitution/dilution of parenteral medications
-provides instructions for eternal preparations
41
*drug monograph: administration
-contains special instructions related to administration with food and missed doses
-recommendations for food or beverages allowable for mixing
-parenteral: infusion information - such as rate of infusion
42
*drug monograph: adverse reactions
-adverse reactions that have been observed in clinical trails/post-marketing
-may be organized by body/organ systems
-may or may not be specific to patient age, provide % incidence
43
*drug monograph: extemporaneous compounding
-if applicable, provided published reference for recommendations related to compounding into oral solution/suspension from tablets or capsules
44
*drug monograph: pharmacokinetics/MOA
-may be necessary for answering drug information questions related to how quickly a medication works, onset of action etc
-half-life can assist with understanding dosing intervals- may be age specific if available
-bioavailability: can assist with parenteral to enteral conversions if not otherwise stated
45
*drug monograph: dosage forms
-available products on market
-brand names and generic strengths available
-assist in determining if commercially available oral solution/suspension is available for pediatric use
-helps to determine timed release products availability
46
what are the most common organisms that cause bacterial men in < 1 month y/os?
-group B strep (GBS)
-E. coli
-Listeria monocytogenes
-klebsiella species
47
what are the organisms that cause bacterial men in 1-23 month year olds?
*S. pneumoniae
*Neisseria meningitidis
-H. influenzae
-E. coli
48
what are the common organisms that cause bacterial mem in 2-50 year olds?
-N. meningitidis
-S. pneumoniae
49
what are the risk factors for developing bacterial men in neonates?
*pre-term birth
*maternal GBS colonization
*traumatic delivery
-low birthweight, chorioamnionitis, maternal endometritis, prolonged duration of intrauterine monitering (> 12 hrs), prolonged rupture of membranes & urinary tract. abnormalities
50
what are risk factors for developing bacterial men in children?
*HIV
*sickle cell anemia
*daycare attendance
*penetrating head trauma
-asplenia, primary immunodeficiency, cochlear implant, CSF leak, recent upper respiratory tract infection, exposure to a case of meningococcal or H. influenza type b memingitis, lack of immunization
51
Presentation of bacterial men in infants
-poor feeding
-vomiting
-fever/temp instabilities
-seizures
-irritability
-lethargy
-bulging fontanelle
52
Presentation of bacterial men. in children
-fever
-headache
-lethargy
-vomiting
-myalgia
-photophobia
-stiff neck
-seizure
-confusion
53
How to diagnose bacterial men
GOLD standard: analysis of CSF from lumbar puncture
- elevated WBC
-elevated protein
-low glucose
-+ bacterial culture
(CI to LP: increased intracranial pressure, coagulopathy, hemodynamic/respiratory instability, skin infection over LP site)
54
Empiric therapy for bacterial men: < 1 month
-ampicillin + AG or
-Ampicillin + cefotaxime
55
Empiric therapy for bacterial men: 1-23 months
-vancomycin + cefotaxime or ceftriaxone
56
Empiric therapy for bacterial men: 2-50 years
-vancomycin + cefotaxime or ceftriaxone
57
Ampicillin therapy dose for neonates: PNA < 7 days
200 to 300 mg/kg/day IV Q8-12h
58
Ampicillin therapy dose for neonates: PNA 8-28days
300 mg/kg/day IV divided q6-8h
59
Ampicillin therapy dose for infants and children
-300 to 400 mg/kg/day IV q6h
-max 12 grams/day
60
Ampicillin AEs
-diarrhea, N/V, rash
-generally well tolerated
61
Cefotaxime dose for bac men in neonates PNA <7 and > 2 kg
100-150 mg/kg/day IV Q8-12h
62
Cefotaxime dose for bac men for neonates PNA 8-28 days & > 2 kg
150-200 mg/kg/day IV Q6-8h
63
Cefotaxime dose for infants and children
225-300 mg/kg/day IV q6-8hrs
-mdd 12 grams/day
64
cefotaxime AEs
diarrhea, nausea, vomiting, rash, prutitis
65
Ceftriaxone for tx of bac men
**do NOT use in neonates due to risk of hyperbilirubinemia
-infants & children: 100mg/kg/day q12h
-adult max dose: 4,000 mg/day
66
Vancomycin dose in neonates PNA <7 & > 2 kg
20-30 mg/kg IV q8-12 h
67
Vancomycin dose in neonates ONA 8-28 days & > 2 kg
30-45 mg/kg q 6-8 h
68
vancomycin dose for infants and children
-60-80 mg/kg/day q 6 h (infants > 3 months - 12 y/o)
-60-70 mg/kg/day q 6-8h ( children > 12 y/o)
69
Vancomycin AUC/MIC
> 400 but < 600
70
Vancomycin adverse effects
*nephrotoxicity
-ototoxicity
-infusion related reactions
71
Dexamethasone adjunctive therapy
-used to decrease hearing loss in pts with H. influenza (> 6 weeks old)
*may be used as adjunctive therapy 10-20 mins before or with 1st dose of abx --> 0.15 mg/kg/dose q 6 hr for 2-4 days
(consider use for s. pneumoniae if high risk of mortality)
72
Prevention strategies of bac. men
-Hib vaccine
-PCV13
-meningococcal conjugate vaccine
73
Risk factors of CAP
*recent hx of upper respiratory tract infection
-lower socioeconomic status
-crowded living environment
-exposure to cigarette smoking
74
Comorbidities with CAP
*asthma
-bronchopulmonary dysplasia
-cycstic fibrosis
-sickle cell disease
-congenital heart disease
75
what are 3 routes that pathogens can enter the lungs?
***: inhaled aerosolized particles
-through the blood stream (less common)
-aspiration
76
Signs and Symptoms of CAP
*fever
*cough
-pleuritic chest pain
-purulent expectorant
-tachypnea for age ( infants > 70, children > 50)
-respiratory distress
-wheezing
-crackles or rales
-pulse ox < 90% on room air
-altered mental status
77
what is used for diagnosis of CAP?
gold standard = chest x-ray
-looking for consolidation - lobar or diffuse
-outpatient diagnosis w/o x-ray if signs/symptoms STRONGLY suggest CAP
-blood cultures
-sputum cultures
-viral testing
-lab tests
78
who should be hospitalized for CAP?
-moderate to severe CAP
-significant respiratory distress
-all infants < 3 months of age
-infants < 6 months of age with suspected bacterial CAP
-suspicion/documentation of community acquired MRSA
-concern for caretaker capabilities
79
what are some bacteria that cause CAP?
**strep. pneumoniae (most common)
-h. influenzae
-staph aureus
-Group A strep
80
Atypical bacteria that cause CAP:
(in older children)
-mycoplama pneumoniae
-chlamydophila pneumoniae
-legionella (rare)
81
Viruses that cause CAP:
(< 2 y/o, 80%)
*influenza virus
-respiratory syncytial virus (RSV)
-parainfluenza virus (PIV)
-adenovirus
-rhinovirus
82
*what is the best predictor of cause via identification of likely pathogen & exposure:
age
83
what are the suspected pathogens for CAP in groups birth - 20 days:
-group B strep
-gram - enteric bacteria
-listeria monocytogenes
84
what are the suspected pathogens for CAP in groups: 3 weeks to 3 months
*S. pneumoniae
-S. Aureus
-RSV
-PIV
-bordetella pertussis
-chlamydia trachomatis
85
what are the suspected pathogens for CAP in groups 4 months - 4 years
*S. pneumoniae
-H. influenzae
-M. pneumoniae
-viruses
-mycobaacterium tuberculosis
86
what are the suspected pathogens for CAP in groups: 5 yrs to 15 yrs
*S. pneumoniae
-H. influenzae
-M. pnuemoniae
-C. pneumoniae
-influenza A or B, adenovirus
-M. tuberculosis
87
what are treatment goals of CAP?
1- provide appropriate empiric antimicrobial therapies to ensure adequate coverage
2. promote antimicrobial stewardship with regard to need for therapy/narrowed therapy
3- ensure pt adherence to prescribed regimen
4- minimize adverse reactions to medications
--> symptom resolution = within 48-72 hrs of tx
88
Outpatient tx of CAP: Amoxicillin dosing
90 mg/kg/day TID (mad daily dose 3-4 g/day)
*must use high dose regimen
(dosage forms: various commercially available suspensions, chewable tablets, capsules, tables)
89
why do we want to use high dose of amoxicillin in outpatient tx of CAP?
-purpose is to overcome strep. pneumo mechanism of resistance (which is the production of penicillin binding proteins)
90
Outpatient treatment of CAP: Augmentin dose
-90 mg/kg/day BID or TID (max single dose 875-1000mg/dose) *must use high dose regimen
dosage forms: want to use the extended spectrum forms (helps to inc the amoxicillin component of drug w/o increasing the clavulanate)
--> food may enhance absorption and decrease GI upset, ADR = diarrhea
91
Outpatient treatment of CAP: what does the clavulanate in augmentin offer?
helps to cover the b-lactamase producing organisms
92
Outpatient treatment of CAP: azithromycin dosing
-10 mg/kg/day on day 1 (MD 500mg) then 5 mg/kg/day days 2-5 (max dose 250mg)
*IV dose = PO dose*
--> food may enhance absorption and decrease GI upset; terrible aftertaste
93
Outpatient tx of CAP: why is only a 5 day treatment course of azithromycin used?
b/c we have a long 1/2 life with a post antibiotic effect
94
Inpatient tx for CAP: Ampicillin dose for empiric, S. pneumoniae (PCN MIC <2) or H. influenzae (beta-lactamase neg)
200 mg/kg/day IV divided q 6 hrs
95
Inpatient tx for CAP: Ampicillin dose for Group A strep
200 mg/kg/day IV q 6 hrs
96
Ampicillin IV AEs
diarrhea, rash, eosinophilia
97
Inpatient tx of CAP: ceftriaxone dosing
500 mg/kg/dose IV q 24 hrs
AEs: diarrhea, rash, eosinophilia, pain at injection site (IM)
98
why is ceftriaxone recommended. in un-immunized children for CAP tx?
concern for H. influnzae (which is beta lactamase producing) and would then need this drug to cover those organisms
99
Antiviral therapy for CAP: Oseltamivir
shown "only to be effective if" initiated within 48 hrs of symptoms
--> dosage forms: capsules, commercially available suspensions 6mg/mL
100
Oseltamivir dose for infants < 1 year
3 mg/kg/dose BID x 5 days
101
Oseltamivir dose for < 15 kg
30 mg BID x 5 days
102
Oseltamivir dose for 15-23 kg
45 mg BID x 5 days
103
Oseltamivir dose for 23-40 kg
60 mg BID x 5 days
104
Oseltamivir dose for > 40 kg
75 mg BID x 5 days
105
non-serious allergies in CAP
-tx recommendations are not defined, trail under medical supervision
-use of cephalosporins: cefodoxime, cefprozil or cefuroxime
106
hx of anaphylaxis to penicillin in CAP tx
can use:
-respiratory fluoroquinolone
-linezolid
-macrolide (azithromycin)
-clindamycin
-bactrim
107
Duration of therapy in CAP
-total 10 days of tx shown to be just as effective as 14 days
-azithromycin & oseltamivir: only 5 days
-CA-MRSA may require longer tx
108
complications of CAP that may require therapy for up to 4-6 weeks or 7-10 days after resolution of symptoms
-parapneumonic effusions
-empyema
-lung abcess
109
complications of UTI
-recurrent UTI
-acute kidney injury
-end-stage renal disease: HTN, dialysis, renal transplantation
110
when/where is UTI more likely to occur?
-in general, higher rates in females and among males, higher rates in uncircumcised
-in children < 12 months who present with fever, UTI prevalence is higher
111
what is the most common pathogen to cause UTI?
E. coli
112
Risk factors for UTI
-younger age groups (neonates/infants)
-female sex
-uncircumcised infants
-constipation
-anatomic abnormalities
-functional abnormalities
-female sexual activity
-immunocompromised state
-diabetic mellitus
-genetic predisposition
113
Infection Pathways: Retrograde ascent (most common)
-enters through urethera and migrates to bladder
114
Infection Pathways: Nosocomial infection
-introduction of foreign body to UT
-more resistant pathogens
115
Infection Pathways: Hematogenous route
-infection originates outside UT resulting in systemic infection with subsequent UT seeding
-more common in infants and immunosuppressed patients
116
Infection Pathways: Fistula (rare)
between UT and GI/vagina
117
lower UTI in bladder
cystitis
118
lower UTI in urethera
urethritis
119
Upper UTI: kidney
pyelonephritis
120
Upper UTI: urine
bacturia (can have asymptomatic cases in older adults --> no need for treatment
121
Complicated UTI
(warrants longer duration of tx)
-GU tract w/ structural/functional abnormalities
-catheters or a UTI that occurs due to a foreign body
122
Uncomplicated UTI
occurs in anatomically normal UT with no prior instrumentation
123
Signs and Symptoms of UTI: neonates
jaundice, failure to thrive, fever, difficulty feeding, irritability, vomiting and diarrhea
124
Signs and Symptoms of UTI: infants and children < 2 y/o
-nonspecific S&S similar to those reported in neonates with the exception of jaundice
-cloudy or malodorous urine, hematuria, frequency and dysuria
125
Signs and Symptoms of UTI in children > 2 y/o
-fever, frequency, enuresis (accidents), hematuria, abdominal pain
126
number of bacteria needed for a clean catch
> 100,000 cfu/mL one 1 bacteria
127
number of bacteria needed for cauterization
> 50,000 cfu/mL of 1 bacteria
128
1st line tx for UTI
-Cephalosporins
-TMP/SMX
-b-lactam/b-lactamase inhibitor
129
When to give parenteral tx for UTI
-acutely ill (septic) children, < 2 months, immunocompromised, unable to tolerate PO
--> continued until patient is afebrile, clinically stable (then switch to oral abx)
130
when to use oral abx in UTI tx
-complete treatment course in patients initiated on parenteral antibiotics
-initial treatment in children who do not meet criteria for parenteral antibiotics
131
what is the antibiotic duration for UTI?
7-14 days
Uncomplicated: 7 days
Pyelonephritis: 10-14 days
132
parenteral antibiotics for UTI tx
-ampicillin
-cefazolin (1st gen)
-cefotaxime (3rd gen)
-ceftriaxone (3rd gen)
-ceftazidime (3rd gen)
-cefepime (4th gen)
-ciprofloxacin
-gentamicin
-tobramycin
133
oral antibiotic options for UTI tx
-amox/clav
-cephalexin (1st gen)
-cefixime (3rd gen)
-cefpodoxime (3rd gen)
-ceftibuten (3rd gen)
-ciprofloxacin
-nitrofurantoin
-TMP/SMX
134
Vedicoureteral Reflux (VUR)
-retrograde urinary flow from bladder into ureters and possibly renal collecting system and renal pelvis
-international reflux study committee classification *grade I-V)
-28% of infants < 6 months old with febrile urinary tract infection have VUR
135
VUR risk factors
-febrile, UTI, parent/sibiling with VUR, prenatal hydropepnrosis (water collected around the kidney in utero)
136
Complications of VUR
-recurrent UTI, renal scarring, hypertension
137
what is the prognosis and treatment of VUR?
Prognosis: spontaneous resolution of vesicoureteral reflux occurs in most young patients within 4-5 years of follow up
Treatment: observation, antibiotic prophylaxis, surgery
138
UTI prophylaxis candidates
goal = prevent irreversible damage (scarring)
--> neonates/infants being evaluated for anatomic or functional UT abnormalities
--> children with VUR
--> children with dysfunctional voiding
--> immunocompromised
--> children with recurrent UTIs despite normal anatomy/function
-prophylactic antibiotics generally continued until resolution of underlying predisposing conditions
139
what were the conclusions of the randomized intervention for children with RIVUR trail
-antimicrobial prophylaxis decreases recurrent UTI
-increased antimicrobial resistance
-no difference in renal scarring
140
what are some viral causes of AOM? (~20%)
-RSV
-rhinovirus
-influenza
-adenovirus
141
What are the bacterial causes of AOM*? (80% of cases)
-step pneumoniae
-H. influenzae
-moraxella catarrhalis
142
What are some infrequent causes of AOM?
-atypical pathogens
-group A strep
-gram - organisms, including pseudomonas
- mixed infections (viral and bacterial) = 2/3 cases
143
Risk factors for developing AOM:
*young age, esp < 2
*day care attendance
*recent viral upper resp tract illness (37% of children with viral URTI will develop AOM)
*nasopharyngeal colonization with middle ear bacterial pathogens
*tobacco smoke exposure
*bottle- feeding
*pacificer use
*sick sibiling in household
144
what are signs and symptoms of acute otitis media?
-middle ear effusion
-acute onset of symptoms: fever, rhinorrhea, irritability, otalagia, tugging/rubbing of the ear
--> otoscopic exam: shows tympanic membrane appears erythematous, cloudy, white, bulging
145
What are signs and symptoms of otitis media x/ effusion?
-uninfected middle ear effusion
-without acute onset of symptoms
-can precede/follow AOM
146
*acute otitis media (AOM):
rapid onset of signs and symptoms of inflammation in middle ear
147
*severe AOM:
-AOM with moderate-to-severe otalgia or fever > 39C (102.2F)
148
*non-severe AOM:
AOM with mild otalgia and temp < 39C (102.2F)
149
*recurrent AOM:
>3 well-documented separate AOM episodes in the past 6 months, or > 4 episodes in past 12 months with > 1 episode in past 6 months
150
Otitis media with effusion (OME or serous otitis media)
inflammation of middle ear with liquid collected in middle ear, but no signs or symptoms of acute infection
151
Chronic suppurative otitis media
continuing inflammation of middle ear for at least 6 weeks, leading to perforated tympanic membrane and otorrhea
152
treatment goals of AOM
-alleviate symptoms: except middle ear effusion - may persist for weeks in up to 70% of children
-preventing recurrence
-using antibiotics judiciously
-ensuring patient adherence
-preventing adverse drug reactions
153
Treatment of OAM: oral analgesics
APAP: 10-15mg/kg
IBU (> 6 months): 10 mg/kg
154
Treatment of OAM: topical analgesics
-anesthetics: antipyrine, benzocaine, lidocaine
-may provide short-term pain relief
155
If pt has any episode of otorreha with AOM (regardless of age)
give antibiotics
156
If pt has unilateral or bilateral AOM w/ severe symptoms
give antibiotics
(otalgia > 48 hrs, temp > 39C)
157
if pt has bilateral AOM w/o otorrhea & is 6 months to 2 yrs old:
give antibiotics
158
if pt has bilateral AOM w/o otorrhea & is > 2 y/o
can do antibiotics or observation
159
If patient has unilateral AOM w/o otorrhea (any age)
give antibiotics or observation
160
First line tx of AOM: amoxicillin criteria
-has not received amoxicillin in past 30 days
-does not have concurrent purulent conjunctivitis
-is not allergic to penicillin
161
First line tx of AOM: amox/clav criteria
-has received amoxicillin in past 30 days
-concurrent purulent conjunctivitis
-hx of recurrent AOM unresponsive to amoxicillin
162
In tx of AOM: if pt has non-life threatening penicillin allergy?
use PO cephalosporin: cefdinir, cefuroxime, cefpodoxime
163
In tx of AOM: if pt has life threatening penicillin allergy
use macrolide: azithromycin, clarithromycin, or clindamycin
164
in tx of AOM: if pt has allergies to penicillin or adherence issues:
ceftriaxone 50 mg/kg IV x1
165
Duration of therapy for tx of AOM
-severe or < 2 y/o: 10 days
-2-5 y/o with mild-moderate symptoms: 7 days
-> 6 y/o with mild-moderate symptoms: 5-7 days
*reassess if symptoms worsen or fail to improve within 48-72 hours
166
Tx of AOM: failure of initial tx steps:
-if stated with amox --> augmentin
-if started with augmentin --> ceftriaxone
-clindamycin (for more rare/failed cases)
167
definiton of recurrent AOM:
> 3 episodes in 6 months
> 4 episodes in 1 yr
168
what is the treatment of recurrent AOM?
-tympanovstomy tubes, adenoidectomy
*prophylactic antibiotics are NOT recommended
169
what vaccines can be administered to prevent AOM?
influenza & pneumococcal vaccine
170
what is appendicitis?
-an acute inflammatory process involving the appendix
-blockage caused by hard mucusy stool or swelling due to a virus may occur
-the blockage causes the appendix to swell and become inflated, risking possible rupture (perforated)
- quick diagnosis is crucial due to the risk of rupture
171
pathophysiology of appendicitis**
-luminal obstruction can cause an increase in pressure within the lumen
-the appendix continues to secrete mucosal fluid, leading to distention
-ischemia, bacterial overgrowth, and eventual perforation follow suit (can lead to ischemia and necrosis)
-w/o diagnosis and tx, the patients symptoms will worse until perforation occurs = bacterial spread throughout the cavaties of the body
172
physical/clinical manifestations of appendicitis
-N/V
-radiating pain in RLQ
-decreased appetite
-fever
-constipation
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4 ways to diagnose acute appendicitis
-physical exam: low grade fever, vomiting etc
-lab evaluation: elevation of WBC count, ansolute neutrophil count (ANC), and/or C-reactive protein (CRP)
-ultrasound: if non-diagnostic, further imaging with CT or MRI is required
-CT scan: modality of choice for definitive assessment of pts (major concern is radiation exposure)
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Fluid therapy & analgesia: IV hydration
-fluid management is CRITICAL
-NS 0.9% or lactated ringers
-1x maintenance is normally used, but can commonly see 1.5x maintenance and. fluid boluses if the pt requires
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Fluid therapy& analgesia: mild pain
-Acetaminophen: not to exceed 5 doses within 24 h, MDD 75mg
-Ibuprofen: infants > 6 months
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Fluid therapy & analgesia: moderate/severe pain
-opioids (morphine = most common)
*rec to AVOID codeine & tramadol --> metabolism variance of CYP2D6
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what 3 bacteria most likely cause appendicitis?
-bacteroides fragilis
-e. coli
-pseudomonas aeruginosa
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IV antibiotics for non-perforated appendicitis
-cefoteratan
-cefoxitin
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IV antibiotics for perforated appendicitis
-ampicillin-sulbactam
-pip-tazo
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2nd gen cephalosporins for appendicitis
-cefotetan & cefoxitin
-gram +: slightly weaker than 1st gen
-gram -: expanded to HNPEK
-cephamycins add anaerobic activity (B. fragilis)
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extended spectrum antibiotics for appendicitis
gram +: streptococci, enterococci, MSSA
gram -: HNPEK, anaerobes (B. fragilis)
**pip/tazo has additional coverage of pseudomonas aerginosa and CAPES orgransims
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what is the criteria for antibiotics to be d/c in appendicitis?
-afebrile
-adequate PO intake/tolerating regular diet
-ambulating
-benign abdominal examination
--> ok to discharge pt home on oral antibiotics (min 5 days of IV antibiotics)
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surgical approaches for appendicitis
-primary treatment for appendicitis is surgery
-laparoscopic > open appendectomy
--> advantages: quicker recovery, shorter hospitalization, lower infection rate/risk
184
complications with appendicitis/surgery
-abscess
-perforation
-sepsis
-shock
-wound infection
185
what is dehydration in peds?
a potentially harmful reduction in the overall fluid/water in the body which occurs when intake of fluid/electrolytes is LESS THAN loss of fluid/electroyltes
186
what are the causes for dehydration?
-fever
-GI losses (viral = most common), bacterial/parasitic, DKA, inborn errors of metabolism, intestinal obstruction/hx of surgical resection, chrons, cyctic fibrosis
-sweating/excessive heat/burns
-polyuria
-imbalance in regulation of sodium/water
--> happen more quickly in neonates and infants than children
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Mild dehydration in infants and children*
I: 1-5%
C: 1-3%
-decreased urine output, slightly dry buccal mucosa
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Moderate dehydration in infants and children*
I: 6-9%
C: 4-6%
-tachycardia, < 1ml/kg/hr urine output, dry buccal mucosa, thirsty
189
Severe dehydration in infants and children*
I: > 10% (> 15 = shock)
C: > 6% (> 9 % = shock)
-rapid and weak pulse, very low BP, oliguria, parched buccal mucosa, very delayed skin turgor, acrocyanosis, no tear, lethargic/comatose, unable to drink
190
*formula for severity of dehydration (% estimated)
[(pre-illness weight) - illness weight) / pre-illness weight] x 100%
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*formula for fluid deficit (L)
% dehydration x pre-illness weight (kg) / 100
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mild to moderate dehydration treatment
--> Oral rehydration therapy
Mild: 50 ml/kg over 4 hrs, reassess q 2 hrs
Moderate: 100 ml/kg over 4 hours, reassess hourly
*add 10ml/kg for each loose stool/vomiting episode
193
Severe dehydration treatment
(shock, failure of ORT, coma/unconscious, abdominal emergency) = IV fluids
1: BOLUS Dose: 10-20ml//kg/dose of 0.9% NS or lactated ringers over 30-60 mins --> repeat up to 3 times based on S/S
2: MAINTANCE:
--> first 8 hrs: calculate and replace fluid deficit
--> next 16 hrs: calculate and provide maintenance rate
194
Components of IV fluid therapy
-sodium: 0.9% NS (isotonic)
-dextrose: D5W
-potassium: 20 mEq/L
195
*Maintenance IV fluid rate: < 10 kg
4 ml/kg/hr
196
*Maintenance IV fluid rate: 10-20 kg
40 mL/hr + 2 mL/kg/hr x (weight - 10kg)
197
*Maintenance IV fluid rate: > 20 kg
60 mL/hour + 1 mL/kg/hr x (weight - 20 kg)
198
Outpatient tx of dehydration: Ondansetron
dose: 0.15-0.3 mg/kg/dose in pts > 6 months
-8-15 kg: 2 mg/dose once
-15-30kg: 4mg/dose once
-> 30kg: 8 mg/dose once
AEs: risk of Qtc prolongation, arrhythmias
199
Outpatient tx of dehydration: Zinc
-can be useful in pts with nutrient deficiencies as cause for diarrhea/malnutrition
< 6 months: 10 mg/day for 10-14 days
> 6 months and children: 20mg/day for 10-14 days
(dosage forms expressed in SALT = 23% elemental)
caps: 50 & 220, tabs: 220mg
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term infant weight
20-30 g/day
-immediatly after brith there is contraction of the extracellular fluid and a significant diuresis occurs that is accompanied by a decrease in weight --> weight should be regained within the first to second week of life
201
failure to thrive in infants
-inadequate growth or inability to maintain growth in early childhood
-weight for age < 5th percentile on multiple occasions
202
treatment for failure to thrive
-breast fed babies: breastfeeding more often, lactation support, formula supp
-formula fed babies: concentrated formulas
other: avoid juice or cow milk consumption, add rice cereal to foods
203
nutrition in breast milk*
20 Kcal/ounce
-breast feed for first 6 months of life --> lots of benefits
204
vitamin D supp in infants
- 400 IU/day, starting in first few days of life
205
fluoride supp in infants
-0.5 mg/day in infants 6 months or older
*only needed for exclusively breastfed infants
--> children should not use fluorinated toothpaste until 2 y/o
206
Iron supp in breastfed babies
full term: 1 mg/kg/day from 4-12 months
pre term: 2 g/kg/day from 1-12 months
207
Iron supp in formula def babies
full term: fortified formula containing Fe 4-12 mg//L until 12 months
per term: additional 1 mg/kg/day to bring total daily dose to 2 mg
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when to use enteral nutrition support
premature neonates younger than 32-34 weeks gentation b/c the suck-swallow reflux is not fully developed
-infants too sick to breast or bottle feed
-pts who are ventilated
-ant ped pt whose needs cannot be met with oral routh
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when to use parenteral for nutrition support
-nutritional needs cannot be met by EN or when the GI tract is not functioning
210
treatment of GER in infants
-use supine sleeping position
-thicken the formula
211
Symptoms of GERD in infants
-heartburn excessive regurgitation, food refusal, abdominal pain or poor weight gain
212
factors that can contribute to decreased LEF pressure in GERD
-tobacco smoke exposure, intake of fatty foods, certain meds, & gastric distention
213
Genetics and risk factors of GERN
-specific locus on chromosome 12
-risk factors: neurologic impairment, obesity, esophageal atresia, chronic lung disease, and prematurity
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Signs and Symptoms of GERD in infants < 1 yr
-regurgitation, vomiting, arching, irritability, poor weight gain, crying
-sandifer syndrome, food refusal, failure to thrive, apparent life-threatening event
215
Signs and Symptoms of GERD in children 1-5 y/o
-regurgitation, abdominal pain, cough
-food refusal, recurrent pneumonia, dental erosions
216
signs of GERD in children > 6
refulx esophagitis
217
initial diagnosis of GERD
-pH monitoring: pH less than 4 for 15-30 sec
-upper GI endoscopy
218
Treatment for GERD: non-pharm
-lifestyle modifications and antirefulx surgery (Nissen fundoplication)
219
H2RAs for GERD tx
-maintenaince therapy for MILD
-quick onset, cost-effective
-no need to taper
-builds tolerance
--> famotidine, nizatidone, cimetidine
220
PPIs for GERD tx
-most potent, heals esophagitis
negs: limited liquid formualtion, ADs, cost, inc infections (c. diff) & rebound
-1st line for maintenance and erosive esophagitis
-CYP2C19 & 3A4 = BID in kids
-taper off over 4 week when therapy is complete
221
surface agents in GERD tx
surcalfate
-coat may heal mucosa, low risk of AEs,
-adjustive to H2RA or PPI in erosive esophagitis
222
hat is the duration of therapy for GERD
12 weeks
223
Live attenuated vaccines (6)
-MMR
-varicella
-rotavirus
-Influenza (LAIV)
-polio (OPV)
-zoster (ZVL)
224
Toxoid vaccines (2)
-diptheria
-tentanus
225
Inactivated vaccines (4)
-Hep A
-influenza (IIV)
-pertisus
-Polio (IPV)
226
Inactivated/recombinant vaccines (3)
-Hep B
-HPV
-RZV
227
Conjugated/polysaccharide vaccines (3)
-HiB
-meningococcal
-pneumoccal
228
Kinrix, Quadracel vaccines are:
DTap + IPV
229
Pentacel vaccine is:
DTaP + IPV + HiB
230
Pediarix vaccine is:
DTaP + IPV + Hep B
231
Proquad vaccine is:
MMR + Varicella
232
Twinrix vaccine is:
Hep A + HepB (the twins)
233
MenHibrix vaccine is:
Hib + MENCY
234
what happens is vaccine is adminsteres > 5 days before the mom dosing interval?
should NOT be counted, repeat when age/time approproate
235
what vaccines are rec and CI in pregnancy?
rec: influenza IIV & TDaP, COVID-19
CI: HPV, influenza (LAIV), MMR, varicella, Zoster
236
vaccine interaction: chemo/radiation
-vaccinate 2 weeks before or 3 months after tx
237
vaccine interactions: systemic corticosteroids --> when is it OK to give?
-topical therapy or local injection
-physiologic maintenance therapy
-low/moderate dose systemic
238
vaccine interactions: high dose corticosteroids for < 14 days
-can vaccinate immediately or wait ~2 weeks
239
vaccine interactions: high dose corticosteroid for >/= 14 days
MUST wait > 1 month to vaccinate
240
what vaccine are given SQ?
-herpes zoster
-MMRV
-meningococcal (MPSV-4)
-PPV23 & polio (also given as IM)
241
CI to LAIV influenza vaccine
-hx of vaccine allergy
-< 2 y/o and adult > 50y/o
-pregnancy
-children 2-4 y/o with asthma or hx of wheezing
-CSF leaks/cochlear implant
-asplenia
-ASA use
-healthcare workers that work with immunocompromised pts
242
PFIZER 6 month to 4 y/o vaccine series
dose 1: 3 mcg, maroon
dose 2: 3-8 weeks later, maroon
dose 3: 8 weeks, bivalent maroon
243
PFIZER 5 y/o vaccine series
dose 1: 10 mcg, orange
dose 2: 3-8 weeks later, orange
booster: 2 months later, bivalent orange
244
PFIZER 6-11 y/o vaccine series
dose 1: 10 mcg, orange
dose 2: 3-8 weeks later, orange
booster: 2 months later, bivalent orange
245
PFIZER 12-17 y/o vaccine series
dose 1: 30 mcg, gray
dose 2: 3-8 weeks later, gray
booster: 2 months later, bivalent gray OR moderana 50 blue cap/gray label
246
MODERNA 6 month- 5yrs vaccine series
dose 1: 25 mcg blue cap/magenta
dose 2: 4-8 weeks later, blue cap/magenta
booster: 2 months later, bivalent pink cap/yellow
247
MODRNA 5 yrs vaccine series
dose 1: 25 mcg blue cap/magenta
dose 2: 4-8 weeks later, blue cap/magenta
booster: 2 months later, bivalent pink cap/yellow OR Pfizer bivalent orange
248
MODERNA 6-11 y/o vaccine series
dose 1: 50 mcg, blue cap/purple
dose 2: 4-8 weeks later, blue cap/purple
booster: 2 months later, bivalent blue cap/ purple OR Pfizer bivalent orange
249
MODERNA 12- 17 y/o vaccine series
dose 1: 100 mcg red cap/blue
dose 2: 4-8 weeks later, red cap/blue
booster: 2 months later, blue cap/gray OR pfizer bivalent gray
250
when do you give HGIB with Hep B vaccine
-given to any neonate with mother status ? or +
< 2kg: 3 additional doses starting at 1 month
> 2 kg: 2 doses
251
9-14. y/o starting date of HPV/Gardasil vaccine:
2 doses, 2nd one 6 months after first
252
15 y/o + or immunicompromised start age of HPV/gardadil vaccine:
3 doses, 2nd one 1-2 after first, 3rd one 6 months after first
253
MMR vaccine
2 doses, starting at 12 months, 2nd dose 4-6 y/o, separate by 4 weeks if pt misses start date
254
International travel situation with MMR
-1 dose should be given at 6-12 months for infant traveling but will not count as real dose and should start series
-unvaccinated > 12 months should receive 2 doses of MMR separated by 4 weeks prior to travel
255
Variecella vaccine age < 13
2 doses, seperated by > 3 months
256
Varicella vaccine age > 13
2 doses, seperated > 4 weeks apart
257
dose series of menveo or menactra
A. dose 1 given at age 11-12 - booster @ 16
B. dose 1 given at 13-15 - booster @ 16-18
C. dose 1 given at > 16 - no booster
-can give menactra and DTap at same time , > 4 weeks after PCV13
258
Bexsero (men B)
-for ages 10-25
2 dose, 1-6 months apart
259
Trumenba (men B)
-for ages 10-25
3 doses, 0. 1-2 months, 6 months
