Module 2.1 (Paediatrics, Childhood Infections, Febrile Seizures) Flashcards
What questions to ask to get all information regarding paediatrics?
Age (or corrected age in pre-term infants)
Weight (actual vs ideal)
Route or acceptable administration methods
Allergies or ADR’s
Family and medical histories and co-morbidities
Medications
Age classification?
Define the following terms:
A) gestational age
B) chronological age
C) postmenstrual age
D) corrected age
A)
- In completed weeks: time between the first day of the last menstraul period and day of delivery
B)
- In days, weeks, months, or years: time since birth
C)
- In weeks: gestational age plus chronological age (CGA)
D)
- In weeks or months: chronological age minus the number of weeks born before 40 weeks’ gestation (only used for children born preterm upto 3 years of age)
What is absorption from the GI tract affected by?
- Gastric acid secretion
- Bile salt formation
- Gastric emptying time
- Intestinal motility
- Bowel length and effective absorptive surface
- Microbial flora
> all these factors are reduced in neonates (full-term and premature) and all may be reduced or increased in an ill child of any age.
How is absorption affected in neonates?
Rate of oral absorption is correlated with age
- ↓ gastric acid secretion (higher gastric pH)
- ↑ gastric emptying time
Immature production of pancreatic fluid and bile salts
Differences in intestinal microbial colonisation
IM absorption
- Decreased muscle mass, erratic blood flow and painful
- Generally should NOT be used – too painful in children (reserved for emergencies or if slower absorption is desired eg Vit K at birth)
Rectal: variation in blood flow to the rectum
Percutaneous absorption
- Enhanced: thinner stratum corneum, better skin hydration, larger SA.
- Potential for systemic toxicity
True or false preterm neonates have
> increased body water content
> less body fat
> lower albumin concentration
> increased blood brain barrier permeability
True
Higher doses (per kg of body weight) of water-soluble drugs are required in younger children because a higher percentage of their body weight is water
true or false
true
Albumin and total protein concentrations are lower in neonates but approach adult levels by 10-12 months = increased pharmacological effects and adverse effects at lower concentrations
True or False
True
Phase 1 and Phase 2 metabolism in neonates ?
Phase 1 metabolism
- Activity is reduced in neonates and increases progressively during the first 6 months of life
- Adult rates of metabolism may be achieved for some medications by 2-4 weeks of age
Phase 2 metabolism
> varies significantly by substrate
- delay in maturation of enzymes required for bilirubin and paracetamol conjugation
- enzymes required for morphine conjugation are fully developed even in pre-term neonates
Summary of drug absorption in neonates
- Drug absorption may be erratic
- Larger volume of distribution may result in the need for relatively larger doses (by weight) than might be expected
- Reduced metabolism and clearance may result in longer half-lives and the need for extended dosing intervals
- TDM may be helpful (in conjunction with clinical review)
> but not effective for valprotate –> doesn’t predict hepatotoxicity in children
What are some drugs that can manifest unusual toxicity in children?
- Ceftriaxone
- Codeine
- Lindane
- Prochloperazine
- Tetracycline
- SSRIs –> suicidal ideation
- Fluoroquinolones
- Diphenoxylate
- Anesthetics, topical (eg benzocaine, mixture of lidocaine and prilocaine)
Should mix medications with breast milk/formula?
No –> may change the taste of it and child may refuse it.
- small amount of apple puree on spoon may be ok
- give favourite food after medicine if necessary to disguise taste
Excipients? What are they linked with?
What measurement should dose be prescribed in?
mg not mL
> Avoid trailing decimals and clearly indicated leading 0’s
> Eg 0.2mg NOT .2mg, 12mg NOT 12.0mg
What should HR, SBP and RR be in children aging from <1 year to 5-12 years?
What formul to use for creatinine clearance in children?
Schwartz clearance, NOT cockroft-gault (>18yo only)
What factors to consider when giving medication to children?
- Age/weight
- Appropriate dose
> when the calculated dose using mg/kg exceeds the adult dose, use the recommended adult dose instead, unless otherwise specified
> Prescribe sensible and practical doses for easy measurement and administration
- Appropriate interval
> don’t confuse total daily dose with dose/interval ‘prn’: include frequency and maximum daily dose
- Appropriate route of administration
- Formulation
- Monitoring parameters
Summary of introduction to paediatrics
Age classification
- Including pre-term infants
Pharmacokinetic changes
Absorption
- Higher gastric pH, increased gastric emptying time, increased percutaneous absorption
Distribution
- Increased body water, lower albumin (less protein binding), increased BBB permeability
Metabolism
- Reduced hepatic enzyme activity in neonates. Most drugs have longer t½ in neonates
Elimination
- Renal plasma flow and GFR gradually improve over the first year or so
Specific medications
- Gentamicin, codeine, theophylline, phenytoin, levetiracetam
Role of TDM?
Adverse effects and toxicity
- Increased risk with paracetamol, valproate, topical anaesthetics, ceftriaxone, codeine, diphenoxylate, fluoroquinolones*, prochlorperazine, SSRI’s, tetracyclines*
Dosing in children
- Mg/kg vs mg/dose vs mg/kg/day vs BSA (mg/m2)
- IBW vs actual body weight
Administration
- How to measure dose
- How to give dose:
> Change medication, change route, tablet, disperse tablet, liquid, extemporaneous, SAS, half/quarter tab, injection via oral route
- Timing of dose
- Excipients
> Can cause issues (eg benzyl alcohol, gluten, ethanol, peanut oil, propylene glycol, colouring agents, carbohydrates)
Medication errors in children
- Inconsistent presentation of dosing information
- Calculations required
- Lack of familiarity
- Unlicensed/off-label use of products
- Different strength products
> Eg paracetamol 24mg/mL, 48mg/mL, 50mg/mL, 100mg/mL
- Parents giving doses in the middle of the night (tired/poor light)
- Child getting into others medication (or other products)
- Poisons information 13 11 26
Paediatric references
- AMH CDC, KEMH, PCH and RCH information etc
Monitoring parameters in children
- Different to adults and vary with age
- do NOT use Cockroft-Gault
What is otitis media? When does it peak? What are the 3 different types?
Inflammation of the middle ear
Peaks between 6 months and 3 years
>Eustachian drainage tube dysfunction
1. Acute Otitis Media (OM)
- Infected effusion and inflammation
2. Otitis Media with effusion
- Effusion but not infected
3. Chronic Suppurative Otitis Media (CSOM)
- infection of the middle ear with a perforated eardrum and discharge for >6 weeks
- Can cause hearing impairment and disability
- Occasionally serious complications can occur
What type of infection if AOM? Is it self-limiting?
Commonly viral infection
> antibiotics often (inappropriately) prescribed
> can also be bacterial or mixed infection
regardless of cause is usually self limiting
> Spontaneous resolution in 80% cases in 2-3 days
> Symptoms may persist up to 8 days in some children
True or false
for AOM: pull on ear and will feel better
for otitis externa: pull on ear and will hurt more
yessir true
How to diagnose acute otitis media?
Middle ear inflammation AND middle ear effusion
> Bulging tympanic membrane
> Otorrhoea (tympanic membrane perforation and effusion) –> discharge from the ear
PAIN ALONE IS NOT SUFFICIENT FOR DIAGNOSIS OF ACUTE OTITIS MEDIA
Acute otitis media where effusion is infected, what other symptoms will there be?
- Acute onset ear pain (tugging, holding, rubbing ear)
- Fever, irritability, poor feeding
- Bulging tympanic membrane
How to manage otitis media? What medications are not used? Why antibiotics not helpful?
Adequate and regular analgesia with paracetamol +/- NSAID
> Antihistamines, decongestants and steroids are NOT beneficial for AOM
> Pain is a poor indicator of response to antibiotic
- For every 100 children treated with antibiotics, only five children will be better at 2 to 3 days due to the antibiotics
- Antibiotic therapy does not improve pain at 24 hours
- Antibiotic therapy can cause harm through allergy, adverse effects and reistance
For most children antibiotics are not required for AOM, who are the exceptions?
Infants <6months
<2 years with bilateral infection
Systemically unwell (lethargic, pale, irritable +fever)
Children with otorrhoea (perforated eardrum)
Aboriginal and Torres Strait islander (ATSI) children
Children at high risk of complications (eg immunocompromised)
For normal patients, what does shared decision making with parent or carer mean for AOM?
Return to Dr if symptoms worsen, or don’t improve in 48-72 hours - antibiotics may be required
A delayed prescription for antibiotic therapy can be provided
Rare complications of AOM (without without antibiotics)
> mastoiditis and facial palsy –> urgent referral
Harms of antibiotic therapy?
- Adverse effects of antibiotics
Diarrhoea, rash or more serious hypersensitivity reactions
- Effect on microbiome
Full consequences not fully understood Yeast infections (eg thrush) to more serious infections (eg Clostridium difficile infection)
- Antibiotic Resistance
Multidrug-resistant bacteria (known as ‘superbugs’) can be spread between people, affecting your family and the community
If antibiotics are indicated for AOM:
A) what to use?
B) if no response to 48-72 hours, what to change to
C) for children with chronic otorrhea, add what?
D) if child very unwell or not responding to therapy?
A)
Amoxicillin
> do not use lower doses
B)
Amoxicillin/clavulanate
> B-lactamase producing H influenzae of M cattarhalis
C)
Ciporofloxacin ear drops until middle ear has been free of discharge for at least 3 days
D)
Urgent clinical review/hospital referral (may require IVABs)
If allergic to pencillins, what to use in place of amoxicillin or amoxicillin + clavulanate?
A) delayed non-severe hypersensitivity to penicillins
B) immediate (non severe or severe) or delayed severe hypersensitivity to pencillins
A)
- cefuroxime for 5 days
- trimethoprim + sulfamethoxazole for 5 days
B)
- trimethoprim + sulfamethoxazole as above
What are risk factors for recurrent bacterial OM?
group child care
allergic rhinitis
adenoid disease
various structural anomalies, such as cleft palate and those associated with Down syndrome
exposure to smoke (eg cigarettes, wood fires)
socioeconomic disadvantage (eg crowded housing)
What vaccination should child have to prevent bacterial OM?
Streptococcus pneumoniae vaccination
What to do if recurrent infection of OM occurs?
Manage as for acute otitis media and consider referral to an otolaryngologist
> frequent recurrences may require myringotomy and insertion of tympanostomy tubes (grommets)
How long does effusion last after resolution of AOM? Does it go away? When would it not be appropriate to wait?
Middle ear effusion can persist for weeks after resolution of AOM
- By 3 months 90% will have resolved spontaneously = wathcful waiting
- May be appropriate to watch and wait 1st 3 months
> Watchful waiting would be appropriate in a child that is not experiencing persistent otitis media with effusion
> A child that is of a non-risk factor category would be indicated for observation (watchful waiting) and would be expected to completely resolve of their symptoms after 3 months (90% of cases)
What are the clinical signs of middle ear effusion?
Grey-white fluid behind an immobile tympanic membrane without signs of inflammation
What is persistent OM with effusion (glue ear) –> how long does it last for? What is the solution?
Middle effusion for > 3 months
- Usually asymptomatic
- May have hearing loss or balance/behavioural problems
- Problem if affecting hearing and speech development
- May need ENT referral and ?grommets
- Some children (eg ATSI children (see guidelines – link in eTG) or children with risk factors for recurrent OM) are at high risk of developing chronic suppurative OM
What are the aims of management of OM with effusion?
Restore hearing (if affected)
Resolve and prevent recurrent infections
Address risk factors for recurrent OM
What is chronic suppurative otitis media (CSOM)? Symptoms?
Is an infection of the middle ear with a perforated eardrum and discharge for >6 weeks
- Non-painful, copious discharge from ear
- Can cause hearing impairment and disability
- Occasionally serious complications can occur
> Intracranial infection and acute mastoiditis
> Increased risk in Aboriginal children
What is the treatment for CSOM?
Dry aural toilet
Topical antibiotic drops
- Ciprofloxacin 0.3% ear drops – 5 drops 12hourly until the middle ear has been free of discharge for >3 days
Persistent discharge may require prolonged treatment –> ENT referral
Summary for AOM
Common presentation in primary care
- Middle ear inflammation AND middle ear effusion
Often viral infection but antibiotics often prescribed
REGARDLESS OF CAUSE IS USUALLY SELF LIMITING
Management
Adequate and regular analgesia
> For most children antibiotics are NOT required
- Shared decision making
- Review or delayed prescription at 24-48 hours
- Risk of adverse effects and increased resistance from antibiotic use
> If antibiotics required:
- Amoxicillin (or if no response or concerns re resistance amoxicillin/clavulanate)
- Penicillin allergy (cefuroxime or sulfamethoxazole/trimethoprim)
Summary for preventing and managing recurrent bacterial OM
Reduce risk factors (smoke exposure, day care)
Pneumococcal vaccination
Consideration of ENT referral and grommets
Summary for otitis media with effusion
Not infected
Persistent OM with effusion if >3mths (Glue ear)
> May present with hearing or behavioural/balance problems
> Restore hearing, resolve and prevent infections, address risk factors
> Consider ENT referral +/- grommets
Risk of chronic suppurative OM (especially in Aboriginal and Torres Strait Islander children
Summary for chronic suppurative otitis media
Infection of the middle ear with perforated eardrum and discharge for >6wks
> Can cause hearing impairment and disability
> Occasionally serious complications can occur
Treatment
> aural toilet and ciprofloxacin ear drops
What corticosteroid to use in severe croup?
Adrenaline by inhalation via nebuliser, repeated after 30 minutes if no improvement
PLUS EITHER
- budesonide by inhalation via nebuliser as a single dose
OR
- dexamethasone orally or IM/IV if vomiting as a single dose
OR
- prednisolone as a single dose
Which drugs used in treatment of influenza? What dose to use in different age groups?
Oseltamivir or zanamivir
Oseltamivir in renal impairment?
Treatment of UTI in infants?
Gentamicin > 1mth – 7.5mg/kg/dose once daily
IV aminoglycosides inactivated by IV penicillins and IV cephalosporins
> Aminoglycosides rapidly bactericidal so give 1st/flush well
Ceftriaxone
- Avoid in <1 mth
- May displace bilirubin from serum albumin
- Caution in neonates with hyperbilirubinaemia
- If < 1mth and penicillin allergic –> cefotaxime
- Do NOT give IV Ca containing products to a neonate on ceftriaxone –> potentially fatal systemic calcinosis (Not within 48 hours (even if via different lines)
- IM very painful – dilute with lidocaine
Paediatric references?
