Introduction to Peds

Question 1

Dosing

Answer 1

Know how to calculate pediatric doses for medications
Usually mg/kg/day or mg/kg/dose (wt in lbs/2.2= wt in kg)

Dosing should be written in mg and mL on the prescriptions
EX: Pediatric ibuprofen dose is 10 mg/kg/dose q 6 hours PRN
2 ½ year old may weigh 14 kg
14 x 10 = 140 mg q6 hours PRN

Question 2

Acute Otitis Media

Answer 2

The most common infection for which antibiotics are prescribed for children in the United States. Maximal incidence is in children 6-24 months of age. AOM is also one of the most common reasons a child is taken to the PCP’s office.

Question 3

Pathophysiology of AOM

Answer 3

Viral Rhinitis &/or Allergic Rhinitis leading to Swelling of the nasal mucosa, nasopharynx, and Eustachian tube leading to Obstruction of the tube leading to Fluid to accumulate (i.e., effusion) leading to Suppuration and inflammation leading to AOM!!

The fluid in the middle ear is secretion from the middle ear leads to effusion.

Question 4

Why is AOM more common in kids?

Answer 4

The ET in children is more horizontal, shorter, and narrower – making it difficult for fluid to drain and more likely for bacteria to invade.

Question 5

Etiologies of AOM

Answer 5

Most Common Viral Agents (Viral causes account for 40-75% of cases of AOM): RSV, Rhinovirus, Coronavirus, Influenza, Parainfluenza, Adenovirus, and Enterovirus

Most Common Bacterial Agents: Streptococcus pneumoniae, Haemophilus influenzae (non-typeable), Moraxella catarrhalis

Question 6

T/F” Strep pneumo is the most common cz of AOM

Answer 6

False, bacterially yes but viral is more common

Question 7

Diagnosis of AOM

Answer 7

Acute signs and symptoms of AOM,
Pressence of middle ear effusion,
Signs or evidence of middle ear inflammation

Question 8

Treatment of AOM:

Answer 8

1st line: Amoxicillin
2nd line: Amoxicillin + Clavulanate (Augmentin)
3rd Choice: Oral 3rd generation cephalosporin
Final Resort: IV or IM 3rd generation cephalosporin

For penicillin allergic patients: Cefdinir, cefpodoxime, or cefuroxime
If a severe reaction: Clindamycin or Azithromycin or Sulfamethoxazole-trimethoprim- not effective against Haemophilus.

For children who are vomiting or cannot tolerate PO meds: Ceftriaxone IM/IV 50mg/kg/day for 3 days

Question 9

Length of Treatment for AOM

Answer 9

10 days for children with severe disease and all children < 2 years of age

5-7 days for children > 6 years with mild to moderate disease

Question 10

Treating the Pain in AOM

Answer 10

OTC options: Acetaminophen. Ibuprofen. Prescription topical analgesia: Antipyrine/Benzocaine: 2-4 drops in affected ear BID to TID (DO NOT use in children with perforated TMs or Tympanostomy tubes)

Question 11

Do not use cold or cough meds in children under 2 yo

Answer 11

ok

Question 12

Complications of AOM:

Answer 12

Tympanosclerosis, TM perforation, Cholesteatoma

Chronic suppurative OM requiring tympanostomy tubes

Question 13

Tympanosclerosis

Answer 13

scarring of the TM by hyalinization and granulation tissue deposition usually secondary to inflammation or trauma.

Question 14

Cholesteatoma

Answer 14

Stratified epithelium that collects in a retracted TM (with possible eventual perforation) that can erode into the middle ear and ossicles and cause conductive hearing loss. They can even erode through the temporal bone and mastoid causing further damage and bone loss.
Pearl *Persistent or recurrent otorrhea should raise concern for a cholesteatoma. Foul smelling otorrhea should, too.

Question 15

Chronic suppurative OM requiring tympanostomy tubes

Answer 15

When persistent otorrhea occurs in a child with tympanostomy tubes or TM perforations
Treatment usually requires therapy with an antibiotic that covers Pseudomonas and anaerobes (fluoroquinolones – PO or topical)

Question 16

TM Perforation

Answer 16

Spontaneous. Most secondary to AOM heal within 2 weeks

Question 17

Mastoiditis

Answer 17

Suppurative infection of the mastoid air cells, which may result in the destruction of the thin bony septae between air cells, followed by the formation of abscess cavities and the dissection of pus into adjacent areas.

Question 18

Mastoiditis Pathogens:

Answer 18

Strep pneumoniae, Haemophilus Influenza, Strep pyogenes, Staph aureus (including MRSA)

Question 19

Mastoiditis Clinical presentation:

Answer 19

Ear pain, Fever, Post-auricular tenderness, erythema, edema, fluctuance, or mass and/or Displacement of the auricle

Question 20

Mastoiditis Diagnosis:

Answer 20

Clinical diagnosis, but imaging may be needed- CT scan

Question 21

Mastoiditis Treatment:

Answer 21

IV antibiotics

Surgical management: Tympanostomy tubes, myringotomy, and mastoidectomy

Question 22

Otitis Externa Pathophys:

Answer 22

Inflammation of the skin lining the ear canal and surrounding soft tissue. Most commonly caused by a loss of the protective function of cerumen and a breakdown of the underlying skin.

Question 23

Common Causes of Otitis Externa

Answer 23

Most common bacterial cause: Staph aureus or Pseudomonas

Question 24

Presentation of Otitis Externa

Answer 24

Pain with movement of the outer ear. May have discharge from the ear. White debris within the ear canal on otoscopy

Question 25

Treatment and Prevention of Otitis Externa

Answer 25

No swimming during the acute phase. Don’t use cotton balls!

Treat with topical antibiotic for 10 days. Flouroquinolones. Use oral antibiotics if systemic symptoms are present

Prevention: Use 2-3 drops of a 1:1 mixture of 70% ethyl alcohol and white vinegar after swimming (in kids whose TMs are intact)

Question 26

Foreign Bodies Signs/Symptoms

Answer 26

Foul odor, Purulent Drainage, Pain, Bleeding, Halitosis

Question 27

FB Management:

Answer 27

Gator Clips, Dermabond or Suction.
If you can’t see it, let the professional get it! May have to treat the inflammation first.

Batteries-must be removed emergently!

Question 28

Allergic Rhinitis

Answer 28

Prevalence: 10-20%. IgE mediated reaction to allergens in the nasal mucosa.

Question 29

Most common allergens of Allergic Rhinitis:

Answer 29

Dust mites, pet dander, cockroaches, molds, and pollen

Question 30

Symptoms of Allergic Rhinitis

Answer 30

Nasal itching, clear nasal discharge, sneezing, postnasal drainage, and congestion

Question 31

Physical Findings of Allergic Rhinitis

Answer 31

Shiners are secondary to venous congestion
Dennie lines are creases under the eyes (Infraorbital folds from venous congestion and edema)
Nasal crease is from rubbing the nose
Pale boggy turbinates secondary to edema
Cobblestoning is secondary to follicular hypertrophy of mucosal lymphoid tissue secondary to chronic nasal congestion and postnasal drainage.

Question 32

Treatment of Allergic Rhinitis

Answer 32

INTRANASAL: Steroids are the Gold Standard (Ex -Nasonex, Flonase, etc…)

ORAL: Anti-leukotrienes (Ex-Singulair (montelukast)) or Oral (and intranasal) antihistamines (Ex- Benadryl, Claritin, Zyrtec, Astelin)

Question 33

Atopic Dermatitis (THE ITCH THAT RASHES)

Answer 33

Chronic relapsing inflammation of the skin due to faulty epidermal barrier.

Many patients experience 3 phases
o Infantile
o Childhood or Flexural
o Adolescent

Question 34

Pathophysiology of Atopic Dermatitis

Answer 34

Faulty epidermal barrier predisposes the patient with atopic dermatitis to dry, itchy skin. Inability to hold water within the stratum corneum results in rapid evaporation of water, shrinking of the stratum corneum, and cracks in the epidermal barrier

Question 35

Infantile Phase of Atopic Dermatitis

Answer 35

Begins on the cheeks and scalp and then as oval patches on the trunk, and later the extensor surfaces of the extremities (–age at onset is 2–3 months, usually lasting to 18 -24 mos)

Question 36

Childhood/Flexural Phase of Atopic Dermatitis

Answer 36

1/3 of kids progress to this phase (–usually affects antecubital and popliteal fossae, neck, wrists, hands, feet.)

Question 37

Adolescent Phase of Atopic Dermatitis

Answer 37

Only 1/3 of the above progress to this

usually just chronic flexural dermatitis and hand dermatitis.

Question 38

Atopic Triad of Atopic Dermatitis

Answer 38

AR, asthma, and AD. Children with asthma or AR have a 30-50% incidence of having atopic derm

Question 39

Treatment of Atopic Dermatitis

Answer 39

Goal: avoid irritants and restore hydration

Use mild soaps and shampoos , Avoid rough clothing, Limit baths, Occlusive emollients should be applied just after bathing (only pat dry), Wet dressings for flare ups

Medical Therapy: Topical steroids are gold standard.

Mild cases: with low potency steroids (Ex-hydrocortisone or desonide).
Moderate cases: medium potency steroids (Ex-triamcinolone or mometasone)

Remember – only low potency steroids on face, axilla, groin, and intertriginous areas ONCE DAILY

Question 40

Complications of Atopic Dermatitis

Answer 40

Most common: Secondary infection is Impetigo

Usually caused by Staph or Strep

Treat topically if possible. Oral- Cephalosporin (Keflex), Clindamycin, Amoxicillin-Clavulinic Acid

Rarer: Vesicular eruption caused by HSV, then Treat with acyclovir

Question 41

Fungal Infections: Candida Albicans

Answer 41

Two forms: Dermatitis: 1)Diaper region, neck folds, axillae 2)Oral: Thrush

Appearance

Treatment: Topical imidazole, such as Nystatin, Oral Fluconazole if severe

Question 42

Fungal Infections: Tinea

Answer 42

Multiple forms: Capitis, Corporis, Cruris, Pedis
Treatment: If hair is involved give Griseofulvin
If skin give Topical imidazole

Question 43

The most common infection for which antibiotics are prescribed for children in the United States.

Answer 43

AOM