Pediatric Disorders Flashcards
Fever without a source
Temp of 100.4 or greater, <96.5, no discernible infection, non-toxic appearance, abrupt onset, <7 days duration
•Age 0-3 months: Admit for CBC with diff, CMP, UA & culture, CSF analysis and culture
•Age 3-36 months, similar workup, but may be managed outpatient if the infant is well appearing.
•If toxic appearing, add HSV workup
Fever of Unknown Origin
Fever> 101.9 for at least 8 days without identified cause. Routine labs have not revealed a source.
- Stop all nonessential medications
- Comprehensive history: Ethnicity. Travel, exposure to animals, insects, risks for HIV, TB, dental health, immunization status
- PE Vital signs, eyes, ears, lymph, lung sounds, cardiac sounds, hepatosplenomegaly, Joints, bones, skin, perianal/rectal
- Diagnostics: *CBC w diff, *CMP, *UA & culture, If toxic looking, add blood cultures serial if suspicious of endocarditis), CSF, *ESR/CRP, *viral cultures (infectious cause), uric acid, LDH, peripheral smear (oncologic source) consider TSH & FT4, ANA, RF, complement, ESR/CRP, ferritin (Autoimmune/Inflammatory), Immunoglobins, lymphocyte markers, antibody titers (immunocompromised)
- CXR, EKG if suspicious of endocarditis
- 30% infectious, 20% autoimmune, 10% oncologic, 5% drug fever (can be caused by acetaminophen, NSAIDS)
*Early testing and assessment can be done in primary care before 8 days, if no identifiable source, admit for further testing
Endocarditis
(Inner lining)
LP- Post CHD Repair
CP- Prolonged fever, rigors, diaphoresis, fatigue, weakness, arthralgias, myalgias, weight loss
A/D- EKG abnormalities, Duke criteria, CBC, BMP, UA, blood cultures, EKG, Echo
T- Pay attention to prolonged fever, Admit for diagnostics, care is antibiotic therapy and supportive to avoid CHF
Myocarditis
(Inflammation of the heart muscle)
LP-Recent infection (viral/bacterial/parasitic/fungal, can be GI infection.
CP-Autoimmune disorders, drug use Shortness of breath, vomiting. abdominal pain, poor feeding,
hypoperfusion
A-Lymphadenopathy, rales, S3 and/or pericardial friction rub, EKG abnormalities (tachycardia, other arrhythmias), hypotension, hepatomegaly
D- EKG, cardiac enzymes, BNP, CXR. Frequently misdiagnosed
T-Admit for diagnostics and supportive cardiac therapy. Other tx is focused on cause.
Pericarditis
(Inflammation of the outer lining of the heart)
LP: Previous infection, autoimmune disorders, trauma, med ADR, likely underdiagnosed and reported.
CP: Classic triad: CP (key element), dyspnea, fever. CP worse with leaning backward, deep breaths, or coughing. Misdiagnosed as pneumonia
A/D: EKG – concave ST elevation, Cardiac ultrasound, CXR (less helpful) No specific labs, but troponin, ESR/CRP elevations, CBC, blood cultures,
T: Admit for diagnostics and supportive cardiac therapy, anti-inflammatory treatment (NSAIDS, glucocorticoids) ABX if infection present.
Kawasaki’s Disease
LP: Ages 3 mos. To 4 years, Asian ancestry
CP: Fever >5 days, polymorphous rash, oral mucositis, bilateral conjunctivitis, erythema of hands/feet, strawberry tongue
A/D: Cervical lymphadenopathy, later stages can include arthralgias, peeling skin (hands, feet) abdominal pain, diarrhea, vomiting,
CBC, ESR/CRP, Echo
T: Admit for diagnostics and supportive cardiac therapy single infusion of intravenous immune globulin (IVIG)
Rheumatic Fever
LP: Indigenous populations, overcrowded living conditions, poverty, peak incidence 5-15 years
CP: Recent sore throat, fever, joint pain
A/D: Chest pain, palpitations, shortness of breath, new murmur, arthritis, chorea, erythema marginatum, and subcutaneous nodules, see Jones criteria in MDCALC
T: Admit: Once dx is confirmed, anti-inflammatory agents
Viral Pharyngitis
LP: sick contact
CP: Sore throat, nasal congestion, cough, nausea, vomiting, abdominal pain
A/D: Check immunization status
T: Analgesics, saltwater gargle, maybe topical anesthetics
Strep Pharyngitis
LP: sick contact, children and adolescents
CP: Sore throat without nasal congestion, cough, nausea, vomiting, abdominal pain
A/D: Pharyngeal exudate, painful anterior cervical lymphadenopathy (consider gonorrhea, chlamydia, HIV – signs of sexual abuse) , scarlatiniform rash in Strep.
Rapid antigen test for strep, If negative but clinical presentation suggests bacterial, throat culture, Monospot
T: Beta lactams: Pen G, Amoxicillin
Teething
LP: Between 6 and 12 months, all teeth erupted by 36 months
CP: Irritability, loss of appetite, difficulty sleeping, drooling.
A/D: None
T: cold (but not frozen) hard rubber teething rings, rubbing the gums with a clean finger , no gels, creams, ETOH for pain recommended. No liquid filled teething rings. Analgesics (not ASA)
Tonsilloliths
LP: After age 20 years, uncommon in children
CP: Sore throat, bad breath, sensation of a foreign body, earache
A/D: Friable or hard solidifications in tonsillar pillars. Clinical diagnosis, but CT could detect stones not outwardly visible Good dental hygiene, saltwater gargles, careful removal with cotton swab
Otitis Media
LP: Most commonly 6-24 months, commonly preceded by a URI
CP: Acute onset, ear pain, irritability
A/D: Bulging TM, poor mobility with pneumatic otoscopy, TM may be yellow, pink, red, but red alone is not diagnostic.
T: Most are viral, analgesics are first line. AOM is most common cause of inappropriate abx, Amoxicillin is first line, although Augmentin can be considered.
<6 mos. Treat with 10-day course
>6 mos. can have analgesics with a watch and wait for 48-72 hours.
Under 2 years, 10 days duration, 2 – 5 years, 7-day duration, >6 years, 5–7-day duration.
Measles
LP: Unvaccinated status, exposure to measles
CP: Fever, cough, runny nose, sore throat, conjunctivitis
A/D: Maculopapular rash, beginning on head, Koplik spots (Red spots with a bluish-white central dot on erythematous buccal mucosa)
IgG/IgM ELISA or PCR
T:Antipyretics/analgesics, supportive, consider Vit A supplementation in children <2 or who have a severe case
Scarlet Fever
LP: 4-8 years
CP: Fever, malaise, sore throat Lymphadenopathy, swollen red tongue, HA, nausea, vomiting, sandpapery rash that starts at ears, moves down trunk and then to extremities. Red streaks in body folds (Pastia lines). Dx’d with rapid strep antigen or with culture
T: Associated with group A strep. Beta-lactam x 10 days. Antipyretics/analgesics, hydration, antihistamines for itching rash
Rubella
LP: Unvaccinated status, exposure
CP: Slight fever, sore throat, runny nose and malaise
A/D: Petechiae on palate and uvula, post auricular, occipital, posterior cervical lymphadenopathy, rash with pink/light red spots beginning on face and spreading to neck, trunk, extremities. Dx IgM/IgG serology,
T: Self-limiting and mild, no treatment necessary except for pregnant women, pregnancy follow up and counseling
Erythema Infectiosum (5th) Parvovirus
LP: Young children, family clusters
CP: Mild fever, headache, can be vague viral symptoms or asymptomatic
A/D: Firm and red cheeks with burning sensation followed by a diffuse lacy rash.
Dx Parvovirus PCR or IgG/IgM serology
T: Usually mild and self-limiting, pregnant women may have complications, follow up and counseling
Roseola
LP: < 2 years
CP: High fever (3-7 days) days), followed by pink macules and papules (2-3 days)
A/D: Erythematous TM, lymphadenopathy (cervical and post auricular). Clinical diagnosis
T: Antipyretics and hydration
Varicella
LP:Unvaccinated status, children 1-9 years
CP: Fever, vesicular rash, mucosal vesicles
A/D: Pruritis, HA, fatigue, sore throat, tachycardia. Clinical diagnosis, but can do PCR testing
T: Acetaminophen (no NSAIDS), antihistamines, IV antiviral therapy for compromised patients, severe cases
Herpes 1 & 2
LP: Immunocompromise, sexual practices,
CP: Vesicles developing into painful ulcers (genital/oral)
A/D: Dysuria, lymphadenopathy, fever,
Dx with viral culture, HSV PCR
T: Oral antivirals for both episodic and suppressant therapies
Cytomegalovirus
LP: Immunocompromise
CP: Generally asymptomatic in immunocompetent individuals.
A/D: If symptomatic, malaise, fever, NVD, visual disturbances. CBC, CMP, Confirmatory test CMV IgM acute illness, CMV IgG past exposure
T: Generally self-limiting, counselling with pregnant women, severely teratogenic, refer immunocompromised patients
Epstein virus
Mononucleosis
LP: None
CP: Fever, pharyngitis, lymphadenopathy, posterior cervical is a key finding
A/D: May be splenomegaly, rash, jaundice, myalgia. CBC, EBV antibodies, Monospot, LFT
T: Rest (controversial), good hydration, antipyretics, and analgesics, Restrict from physical activity 2-4 weeks after infection (confirm resolution of splenomegaly prior to activities)
Molluscum Contagiosum
LP: Common, close contacts
CP: Smooth, pearly papules, pruritis, accompanying dermatitis
A/D: Facial or groin distribution of lesions. Clinical dx, dermoscopy or biopsy can be used to confirm.
T: Self-limiting in immunocompetent patients, Limited evidence for salicylic acid, benzoyl peroxide, and tretinoin, cryotherapy. Refer immunocompromised patients or those with possibility of facial scarring
Coxsackie
Hand, foot, mouth disease
LP: < 10 years
CP: Low grade fever, oral vesicles, rash or vesicles on hands and feet
A/D: Malaise, anorexia, sore throat, abdominal pain, diarrhea, cough
Clinical diagnosis, can also do CBC, viral culture
T: Generally self-limiting, analgesics, topical anesthetics
Mumps
LP: Unvaccinated status
CP: Swelling/pain of parotid glands
A/D: Constitutional symptoms, orchitis, oophoritis. Clinical diagnosis, but can do viral culture of saliva, CBC, antigen PCR, antibodies,
T:Supportive care with hydration, analgesics, antipyretics
Hyperthyroidism (Grave’s Disease)
LP: Peak incidence 10-15 years
CP: Same as adult – nervousness, weight loss, heat intolerance, tachycardia, tremor
A/D: Enlarged thyroid, TSH, FT4, iodine uptake scan, autoantibodies
T: Referral endocrinology, beta blocker for symptom relief, 6-month follow-up
Hypothyroidism
(Hashimoto’s disease)
LP: Congenital or acquired (Hashimoto’s disease)
CP: Same as adult – weight gain, lethargy, cold intolerance, can be subclinical or nonspecific symptoms, delayed development, short stature
A/D: can be subclinical delayed development, short stature. Enlarged thyroid, TSH, FT4.
Consider antithyroid peroxidase antibodies, lipid panel, CBC, thyroid scan
T: Thyroid replacement therapy
Insulin Dependent Diabetes
LP: Any age, peak 10-14 years, family history
CP: Polyuria, polydipsia, weight loss, and weakness.
A/D: Blurred vision, N&V, abdominal pain,
Dx: random, fasting glucose, HbA1c, consider fasting C-peptide, autoimmune markers
T: Referral endocrinology, basal bolus insulin regimen, diet management, activity management, self-monitoring blood glucose
Anabolic Steroid Use
LP: Male, history of sports/physical activity, hx of dysmorphic disorder
CP: History of increased appetite/food consumption, rapid weight gain increased muscular build.
Chronic use can result in dermatologic, psychiatric, sexual effects.
A/D: May not seek treatment for steroid use specifically, maintain high level of suspicion. Acne, hirsutism & menstrual irregularities(females), scrotal pain, higher pitched voice (males), hostility, aggression, irritability, labile mood
Urine toxicology, urinary ratio of testosterone glucuronide to epitestosterone glucuronide. FH, FSH, CBC, CMP, lipid panel, hepatitis panel, HIV, CK
T: Manage complications of withdrawal, counseling, psychotherapy, nutrition counseling. Assess for other substance abuse. Consider referrals to mental health, endocrine, cardiac or other professionals depending on effects and comorbidities
PCOS
LP: Symptoms begin at puberty, family history, obesity
CP: Irregular menstruation, hirsutism
A/D: Serum 17 hydroxyprogesterone, prolactin, TSH, glucose tolerance, lipid panel, consider total and free testosterone, LT< FSH, ultrasound, basal body temperature.
T: Desiring fertility: weight loss, metformin adjunct
Not desiring fertility
OCP, metformin adjunct
Precocious Puberty <8 girls, <9 boys
LP: Sexual abuse a risk factor
CP: Development of secondary sex characteristics before 8 (girls) or 9 (boys), tall stature
A/D: Bone age assessment, serum testosterone, estrogen, FSH, LH, LNRH stimulation test, pelvic u/s. consider head CT, MRI, pituitary function tests, TSH, u/s adrenals
T: Refer endocrinology, Referral for associated brain neoplasms, hypothalamo-pituitary tumors; and neurodisability
Treat is replacement of androgens until puberty ends and/or management of precipitating conditions
Adrenal Insufficiency (Addison’s)
CP: Non-specific symptoms, fatigue,
T: Refer endocrinology, mineralocorticoid and glucocorticoid replacement for life,
Dysphagia
LP: pharyngeal, laryngeal or esophageal lesions; foreign bodies; anatomic abnormalities; physiological dysfunction; neurological dysfunction; tumors
CP: Progressive dysfunction, reports from patient of pain or food getting stuck after swallowing, child preferring liquids to solids, child refusing feedings
A/D: Observe feeding and child’s ability to swallow. Look for choking, vomiting or regurgitation. Palpate child’s neck for masses
Lateral neck films, barium swallow, fluoroscopy
T: Directed at cause
Pyloric Stenosis
LP: 3–6-week-old
Males 4x that of females, firstborn
CP: Vomiting, feeding intolerance with multiple formula changes, constipation, dehydration.
A/D: Failure to thrive/weight loss, irritability, signs of dehydration, olive shaped mass in upper abdomen
Dx u/s upper abdomen, BMP
T: Fluid and electrolyte replacement, then surgery
Appendicitis
LP: Between 10 and 30, highest incidence in children and adolescents
CP: Acute abdominal pain starting in the mid-abdomen, nausea, vomiting
A/D: Decreased bowel sounds, tachycardia, positive obturator, Psoas, Rovsing’s signs
CT lower abdomen and pelvis, CBC, CRP, HCG if relevant
T: Refer surgery
Colic
LP: < 5 mos.
CP: Paroxysms of uncontrollable crying in an otherwise healthy and well-fed infant, >3 hours per day, and >3 days per week, for at least 3 weeks.
Dx of exclusion, review for other causes, absence of nausea, vomiting, distended abdomen, AOM. Dx: UA, urine culture, Xray of any suspected injuries, abdominal x-ray
T: Education on feeding, burping, avoidance of excess of stimulation, parental support, this is highly stressful.
Intussusception
LP: Ages 3-12 mos., peak at 9 mos. , males >females
CP: Colicky abdominal pain, flexing of the legs, fever, lethargy, vomiting, may have blood in the stool , a preceding viral illness.
A/D: Colicky abdominal pain, vomiting, lethargy, hypovolemic shock, U/S, abd x-ray
T: Fluid resuscitation, barium enema
Hirschsprung’s
LP: 1st year of life, Trisomy 21 at higher risk
CP: Vomiting, abdominal distension, explosive diarrhea and/or enterocolitis.
A/D: Failure to thrive, Plain abdominal x-ray, contrast enema, confirmed by rectal biopsy.
T: Newborn: Colonic irrigations, surgery depends on severity of disease. If enterocolitis, IV fluids and abx.
Celiac
LP: All ages most diagnosed <20 years, peaks at weaning and in in 30’2-40’s, high risk includes autoimmune disease, FH of celiac disease, type 1 diabetes, lack of IgA
CP: Diarrhea, bloating, abdominal discomfort, herpetiform rash,
A/D: Anemia, autoimmune disease, failure to thrive, NVD, constipation, flatulence, fatigue, paresthesia, delayed growth, delayed puberty,
PE: skin (psoriasis, atopic dermatitis), easy bruising, brittle nails. EENT: Oral aphthous ulcers, loss of tooth enamel, neuro: neuropathies, Psych: mood disorders. Testing: CBC with smear, IgG-tTG, IgA-tTG, IgG DGP(celiac panel). Consider small bowel endoscopy, biopsy (controversial)
T: Diet counseling, lifelong gluten free diet, assess and treat vitamin deficiencies (iron, vitamin D, vitamin B12, and folate), calcium and Vit D supplements, bone density studies after 1 year of tx.
Vomiting
Key assessment to keep in mind
FH, PMH, SH, Hospitalizations
Recent antibiotic use
Medications including homeopathic, OTC
Recent exposure to illness, injury or stress
Relationship of vomiting to meals, time of day, activities
Presence of associated symptoms: diarrhea, fever, ear pain, UTI, visual changes, head trauma, headaches, high pitched cry, seizures, anorexia
Cyclic vomiting Syndrome (CVS): acute attacks of vomiting, noticeable pattern day to day. Not the same as recurrent.
Acute Abdominal Pain Possible Causes
Obstruction: adhesions, strangulated hernia, neoplasms
Inflammation: cholecystitis, acute pancreatitis, acute APPY, diverticulitis, ulcerative colitis, Crohn disease
Perforations: gastric ulcer, Mallory Weiss tear
Gyn: ectopic pregnancy, PID, endometriosis
DKA, Opiate withdrawal
Infectious: gastroenteritis, hepatitis, infectious colitis
Sickle cell crisis, testicular torsion
Acute Diarrhea Possible Causes
urgent concern is dehydration
Viral, bacterial, parasitic infections
Medications
Inflammatory bowel disease
IBS
Chronic Diarrhea Possible Causes
Colonic: Inflammatory bowel disease , Infective gastroenteritis (bacterial/viral/parasitic), ischemic colitis
Small bowel: Celiac disease, Crohn disease, bacterial overgrowth, lymphoma
Small bowel bacterial overgrowth
Pancreatic: pancreatitis, Cystic fibrosis
Functional: IBS
Metabolic: Hyperthyroidism, diabetes, hypoparathyroidism, Addison disease
Medication effects
Fecal impaction
Constipation Possible Causes
Hirschsprung disease
Anorectal anomaly
Anal fissure
Sexual abuse
Myotonic dystrophy
Cow milk intolerance
Celiac disease
Crohn disease
Vomitting
PE: Look for volume depletion, fever, pallor, lethargy, extremity perfusion, neurologic signs, confusion, tachycardia, hypotension, hyperventilation,
A/: Red flags: Recurrent vomiting, rather than cyclic. Neurological or Developmental abnormalities. Evidence of encephalopathy .
CBC, CMP, Amylase, serum ketones, urine culture, and urinalysis. Consider ABG, consider toxicology screen, consider hepatitis panel.
Abdominal Xray, u/s, CT, consider MRI/CT of head
T: Focused on cause, rehydration and electrolyte balance.
Admission for toxic appearing child
Acute Diarrhea
LP: All ages, infants prone to rotavirus in not vaccinated
A/D: Assess for hydration, skin integrity
T: Focused on causes, in all patients, rehydration and electrolyte balance, skin integrity
Chronic Diarrhea
PE: Abdominal and neuro exam, rectal exam (bruising raises suspicion of abuse)
A/D: No primary tests, diagnostics aimed at likely causes, abd/pelvic u/s, abdominal Xray, colon transit study, psychological evaluation
T: Focused on causes, in all patients, rehydration and electrolyte balance, skin integrity
Constipation
LP: Low Birth Weight, infants weaning, toddlers learning toilet skills, school age. Withholding peaks at 2-3 years and fecal incontinence is frequent RFV, low fiber diet, poor nutrition, psychiatric history, obesity.
Functional constipation in school age
A/D: Rectum and anus for fissures, causes of painful defecation, abdominal exam, full neuro exam, dietary history. No initial diagnostic tests, consider abd U/S, x-ray, pelvic U/S, transit studies in certain cases, suspected impaction Explore child’s perception of safety in public toilets.
T: Focused on likely cause, eliminating cow milk, increasing fiber and hydration, counseling,
Stool softeners. Goal is to reduce pain and increase frequency of stool.
Trial of dairy-free diet, increase physical activity in older children
Osmotic laxatives and stool softeners
ADHD
LP: 4-18 years, maternal nicotine use in pregnancy, lbw, family history, epilepsy., males but likely underdiagnosed in females
CP: Easily distracted, fidgets, excessive motor and verbal activity, schoolwork or play activities disrupted. Hyperactivity more prevalent in younger children, inattention in adolescents Rule out mood disorders, anemia, lead, visual, cognitive or language disability abuse, seizure disorder, thyroid disorders, stress, medications, substance abuse. Narratives from teachers, caregivers, tutors, counselors etc.
Developmental hx, family hx, social hx, patterns of behavior.
T: Collaboration with mental health professionals essential. Behavioral therapy first line for younger children, but should be used for all children, parental education and support. Stimulants for school age children and older are first line.
Anorexia Nervosa
LP: Females, adolescence/puberty, males most likely underdiagnosed
CP: Most often diagnosed through parent interview or weight checks at routine visits. Assess weight at routine visits. If wt is significantly low, set up weekly visits for wt check. BMI <5th %ile is red flag
A/D: Detailed dietary hx, r/o comorbid psych disorders, (OCD is common), disruption in individual growth curve, menses,
CBC, CMP, TSH, FT4, magnesium, Phosphate, CK, if amenorrhea, HCG, estrogen, LH, FSH, consider testosterone levels in males, prolactin, consider bone density scan, fat soluble vitamin levels. ECG for arrhythmias,
T: Team approach across spectrum of care (outpatient to hospitalization) Mental health counseling, diet supplementation, monitor fluid intake, individualized for each patient, may need enteral nutrition.
Bulemia Nervosa
LP: Females, peak at 25-30 years, males most likely underdiagnosed, likely obesity
CP: History of binge eating, frequent vomiting, frequent diets, GI symptoms, marked fluctuations in weight,
A/D: If frequent vomiting, assess loss of tooth enamel, swollen parotids, consider all above in anorexia nervosa + HCG
T: Team approach across spectrum of care, CBT, family therapy, psychoanalysis, SSRI, SNRI, Individualized nutrition counseling. Consider self-help groups and telemedicine approaches
Conduct Disorder
LP: Males>females, ages 3-17, prenatal exposure to toxins, maternal mental health disorders, coercive parenting style
CP: Ages 3-7: defiance, angry outbursts, physical aggression, destruction of property
Ages 8-11: physical fights, cruelty to animals, fire-setting, stealing, ages 2-17 all above + assault, robbery, vandalism, truancy.
A/D: Psychiatric evaluation. Collect information from multiple sources, Assess for comorbid mental disorders, hx of sexual abuse, substance use, epilepsy, learning disabilities, assess family risk factors, neurodevelopmental history, prenatal history
T: Multisystem – family therapy, cognitive therapy, behavioral therapy.
Refer
Transient Tic Disorder
LP: Males>females, onset <18 yrs. Hx of maternal nicotine, hx of family OCD disorders
CP: Involuntary repetitive movements and or sounds, usually brief, sudden, increase in stress or anxiety.
A/D: Classify type based on duration and motor, phonic, or mixed. Assess for comorbid mental disorders, primary tics will have normal neuro exam, assess for secondary causes such as infections, TBI, substances, toxins, neurologic disorders (full neuro exam), no specific tests, consider head MRI, CSF eval, EEG. Rule out seizures, chorea, dyskinesia,
Consider urine tox, TSH, FT4
T: Mild tics do not required treatment. Treat when tics interfere with daily activities and QOL. CBT, HRT (Habit reversal training), medications include dopamine antagonists (antipsychotics) alpha 2 agonists, benzodiazepines. ECG prior to medications for baseline
Tourette’s
LP: Rare, mean age 5-6 years, usually resolves by age 18, greatest severity at 10 years, males>females
CP: Motor and phonic tics that wax and wane, premonitory
A/D: Assess for comorbid mental disorders, esp ADHD and OCD,
Other diagnostics as above
T: Mild symptoms do not required treatment. Treat when tics interfere with daily activities and QOL. CBT, HRT (Habit reversal training),
Approved meds are haloperidol, pimozide, and aripiprazole. ECG baseline prior to medications
PANDAS
LP: Post group A strep disorder, family history of tic disorder, OCD, or acute rheumatic fever, onset before puberty, maternal autoimmune disease
CP: Abrupt onset of OCD, tics, food refusal, anorexia. Begins up to 3 days before GAS infection symptoms, can appear up to 30 days after.
A/D: Family hx, autoimmune disorders, (ANA), full assessment for strep infection, GI assessment, full neuro assessment, assess for mycoplasma, influence, Lyme,, r/o endocrine, neurologic, CBC, CMP, ESR/CRP, throat culture, titers for streptococcal infections, UA.
T: Treat for strep (regardless of cultures and titers)
Refer for psychiatric assessment and treatment
Croup
LP: 3-36 months, likely preceded by parainfluenza, peaks in late Autumn, winter months
CP: Insidious onset barky cough, stridor, intercostal retractions, worse at night, URI symptoms preceding croup
A/D: Assess severity and potential respiratory compromise, r/o GERD, pneumonia, epiglottitis (vaccination status), wheezing, drooling, toxic appearance (consider alternative dx) Clinical diagnosis. If unresponsive to treatment, consider CBC, CT of neck , CXR
T: If mild- moderate, nebulized racemic epi and one time injection dexamethasone, retractions should resolve within 2 hours, surveillance. Otherwise admit for more intensive care
Epiglottitis
LP: Vaccines incomplete, occurs at any age, infants <12 mos. are at high risk
CP: Abrupt onset, high fever, severe sore throat, dysphagic, drooling. Do nothing that can upset the child, no pharyngeal assessment, transfer to ED is suspected.
T: Life-threatening, emergency admission
Congenital Laryngomalacia
LP: Infants peaks at 6-8 months, starts as early as 2 weeks, Assoc with Down’s syndrome or CHD
CP: Recurrent inspiratory stridor, recurrent croup, feeding difficulties, coughing/choking during feedings
A/D: Recurrent croup is a red flag for structural anomalies. Always consider Xray in cases of recurrent croup, diagnosed with flexible laryngoscopy
T: If mild, watch and wait, if there is nutritional or respiratory compromise, Endoscopic supraglottoplasty
Subglottic Stenosis
LP: Traumatic (Hx of intubation ) appears after insult. Congenital appears in very young neonates
CP: Recurrent inspiratory and expiratory stridor, otherwise similar presentation to laryngomalacia, stridor supine AND prone
A/D: Lateral neck x-ray, CXR, flexible laryngoscopy may miss dx, rigid laryngoscopy
T: Endoscopic dilation for most cases. Refer
Foreign Body Aspiration
LP: 1-2 years of age most common, > 1-year right bronchus. If item is small to air trapping
CP: Choking, coughing, hoarseness, decrease lung sounds, asymmetry is key finding
A/D: CXR, inspiratory and forced expiratory, indicates asymmetry. Inhaled vegetable matter will not show up on x-ray, commonly diagnosed as recurrent croup, croup, asthma, bronchitis, pneumonia, URI. Need a good history of onset and any triggering events.
T: Removal with bronchoscopy
Bronchiolitis/RSV
LP: RSV usually, inflammation in distal airways, air trapping,
First 2 years of life, winter disease, leading cause of hospital admission in infants <1 yr.
CP: Mild URI, coughing, fever, tachypnea, resp distress, transient apnea, diffuse, exp wheezing
A/D: Differentiate from asthma by clinical signs
Higher incidence of asthma in later life. Link with atopy
T: Supportive care, hydration, monitoring, if resp distress in severe cases, hospitalization, trial of Beta 2 agonists. No ribavirin usually, no steroids unless in ICU. Prevention with high-risk infants w Palivizumab (D-MARD)
Pneumonia
LP: Usually viral, in children <5, >5 Mycoplasma, chlamydia, pneumococcus, strep. Chlamydia 1-3 mos., staccato cough
Inflammation of lower airways
CP: Viral: insidious onset, low grade fever, nontoxic looking, wheezing, crackles
Bacterial: acute onset, high fever, toxic looking, decreased LS
A/D: CXR (looks worse than child)
In viral – interstitial consolidation, Bacterial – lower lobe infiltrate, WBC to 10,000, bands,
Focal infiltration likely strep
Treat empirically
T: Viral : symptomatic care,
Bacterial : 3rd gen cephalosporin if pneumococcus, macrolide, may need to be hospitalized
Cystic Fibrosis
LP: Caucasian, exocrine, impaired Cl- and therefore Na+ and H2O, water loss, dry think resp secretions
CP: Fat malabsorption, wt. loss, FTT, steatorrhea, loss of Vit ADEK, respiratory distress, repeat infections, wheezing, pneumonia,
A/D: Multiple other sx, genetic origin, nasal polyps may be presenting sx, rectal prolapse, acute pancreatitis, sx of hypoxemia. Resp organisms staph aureus, later pseudomonas,
T: Pancreatic enzymes, vitamin supplementation, airway prophylaxis, followed by specialists
SIDS
LP: Highest incidence 4-6 mos., single most important trigger is prone sleeping
CP: No other findings of death.
T: Prevention is key, parent education on back to sleep, bare crib, no co-sleeping.
Asthma
LP: Ages 3 years and older. Preterm, LBW infants, FH of atopic conditions, hx severe RSV, exposure to air pollution, irritants, obesity,
CP: Recurrent wheezing, dry cough (at night/early morning), shortness of breath
A/D: Assess for severity, frequency of symptoms, triggers for symptoms, other atopic symptoms, FH, SH and environment, limited physical activity, skin/EENT, Resp/Cardiac assessments.
Dx: Spirometry, peak-flow >5 years, younger, use GINA guidelines, trial of treatment/response
T: Based on severity rating, mild intermittent . Goal is no daytime /nighttime symptoms, no need for rescue med, no exacerbations, full activities. Peak expiratory flow (PEF) >80% predicted
Environmental controls, self-management, education.
Asthma Severity Rating
Back Pain
LP: Any age, the older the child, the more likely the origin is musculoskeletal.
A/D: Reports of pain, stiffness.
CP: Red flags: weakness, self-limited activities, constitutional symptoms, bowel or bladder incontinence, or pain that awakens patient’s from sleep . Full musculoskeletal exam, neuro exam, Consider CBC, ESR/CRP, ANA, RF. AP and lat back x-ray, add lumbar and oblique for lumbar pain, MRI
T: Consider a referral to pediatric orthopedist, muscle strains to PT. Refer any children/adolescents with red flag symptoms
Scoliosis
LP: Between ages 10-18
CP: Usually painless, dx’d on screening, uneven shoulder height, unequal scapula, unequal muscle mass, forward bend test.
A/D: Growth spurts, functional limitations, Red flags: back pain, alterations in sensation or motor control. Gait, neuro and skin assessment, LLE length discrepancy. Diagnosis of exclusion. Standing AP and lat x ray, MRI
T: 90% will not need treatment, based on initial deformity, rate of curve progression, overall assessment of growth potential. Exercise, surveillance, bracing, surgery
Legg-Calf Perthes
LP: Males, ages 4-8 years, low socioeconomics, coagulation disorders
CP: Short stature, painless limp, limited hip ROM,
A/D: Asymmetric limb length, Bilateral hip x rays, muscle wasting, knee and/or hip pain, positive Trendelenburg
T: Manage acute pain, casting, surgical intervention, refer
Osgood-schlatter’s
LP: Adolescence, during growth spurt, active in sports,
CP: Tibial tubercule pain and local tenderness, tibial tubercle pain on leg extension
A/D: Clinical dx, x rays knee U/S, MRI
T: Rest, ice, NSAIDS, PT, if unresponsive, bracing
Talipes Equinovarus
LP: FH, males >females,
CP: Can be dx’d prenatally,
A/D: Not definitive test,
T: Refer orthopedics
Radial head subluxation
LP: 6 months to 7 years
CP: Hx of forceful traction on extended, pronated arm. Generalized pain in arm on movement, tenderness of radial head.
A/D: Evaluate clavicle, shoulder, entire arm to r/o injuries, significant tenderness, swelling, bruising, or deformity suggests serious cause such (supracondylar fracture), if suspected fox, AP & lat elbow x-ray
T: Pain management, Internal reduction
Hip Pain Possible Causes
Infants and children <3
- toddler’s fracture - nondisplaced fracture of tibia in infants and children aged 9 months to 3 years
- septic arthritis - most common cause of severe monoarticular pain
- osteomyelitis
- previously undiagnosed developmental dysplasia of the hip
- transient synovitis of the hip
- congenital limb length discrepancy
- cerebral palsy
- spinal abnormalities
Hip Pain Possible Causes
Children aged 3-10 years
- trauma/fracture
- transient synovitis of the hip
- septic arthritis
- osteomyelitis
- juvenile idiopathic arthritis
- Legg-Calve-Perthes disease
- developmental dysplasia of the hip
Hip Pain Possible Causes
Children and Adolescents Aged 11-18
- trauma/fractures
- overuse syndromes
- septic arthritis
- slipped capital femoral epiphysis (SCFE)
- juvenile idiopathic arthritis
- reactive arthritis
- tumors
