Pediatrics Flashcards
SIRS & sepsis criteria in children
2/4 of following with at least 1 being temperature or leukocyte count
-Temp >38.5C or <36C
-Tachycardia over 30 min- 4 hours or bradycardia over 30 min
-Tachypnea
-Leukocyte elevation or depression, or >10% immature neutrophils
If active infection - then it is considered sepsis
Septic shock in children
severe sepsis (sepsis + end organ failure, ards) persists AFTER 40ml/kg fluid bolus
Need for vasopressors
metabolic acidosis
oliguria
increased lactacte
prolonged capillary refill
core to peripheral gap >3C
Bacterial VS Viral meningitis CSF in children
WBC:
>1000 (bacterial) 100-500 (viral)
Neutrophils:
>50 (bacterial) >40 (viral)
Glucose:
<30 (bacterial) >30 (viral)
Protein:
>100 (bacterial) 50-100 (viral)
RBC:
0-10 (bacterial) 0-2 (viral)
0-1 month old common pathogens for meningitis/sepsis, preferred empiric tx
Early onset:
GBS* most common
E. coli
L. monocytogenes
Late onset:
Viral
CNS
Gram-negatives (Klebsiella, Pseudomonas, Enterobacter)
Ampicillin + gentamicin
may consider ampicillin + ceftazidime if concern for meningitis
1-3 month old common pathogens for meningitis/sepsis
GBS* most common
E. coli
L. monocytogenes
H. flu (less now b/c of vaccine)
N. meningitidis
S. pneumo
Ampicillin OR vancomycin + ceftriaxone or cefotaxime or ceftazidime
No concern for meningitis = leave out vanco.
3mo-12 year common pathogens for meningitis/sepsis
H. flu (les b/c of vaccine)
N. meningitidis
S. pneumo
Ceftriaxone + vancomycin
Add antipseudomonal agent if nosocomial infection
> 12 y/o common pathogens for meningitis/sepsis
N. meningitidis* most common
S. pneumo
Ceftriaxone + vancomycin
Add antipseudomonal agent if nosocomial infection
Steroids in pediatric meningitis
May reduce hearing loss from Hib only
Administer before or at same time as first antibiotic
Dexamethasone 0.15mg/kg/dose q6H x2days
Ex to use: child with s/s of meningitis has recent Hib exposure
N. meningitidis chemoprophylaxis
Preferred: Rifampin
<1 mo: 5mg/kg/dose q12h x2 days
>=1 mo: 10mg/kg/dose q12h x2 days
Alt: Ceftriaxone 125mg IM (>=15 y/o = 250mg)
Alt: Ciprofloxacin 20mg/kg/dose PO x1
H. flu chemoprophylaxis
<1mo: rifampin 10 mg/kg/dose daily x4 days
>=1 mo: 20 mg/kg/dose daily x4 days
“high risk group” that need chemoprophylaxis from N. meningitidis and H.flu
household contacts
daycare
direct contact w/ secretions 7 days before or 24 hours after ABX
prolonged contact (4-8 hours) in 7 days before
neonatal meningitic symptoms
bulging fontanelle, seizures
infant/children meningitis symptoms
nuchal rigidity, kernig sign, brudzinski sign, photophobia, HA, AMS, seizure, bulging fontanelle
Nirsevimab
MAB indicated for RSV prophylaxis
Indicated for all infants <8mo. during their first RSV season
indicated from 8-19 mo during second RSV season IF high risk factors
<5kg: 50mg
>5kg: 100mg
8-19mo: 200mg
During RSV season (oct -late jan) administer within first week of life
Can administer with other vaccines
Palivizumab
MAB for RSV prophylaxis
ONLY recommended for high risk infants IF nirsevimab is unavailable
High risk = extremely premature, chronic lung disease, congenital heart disease, pulmonary HTN, immunocompromised
15mg/kg/dose IM monthly during RSV season for 5 doses
RSV treatment
Supportive cares
Ribavirin in select high risk patients but routine use not recommended
No treatments are shown to improve outcomes or mortality (bronchodilators, racemic epi, steroids, inhaled hypertonic saline)
Acute Otitis Media definition
Middle ear effusion (bulging tympanic membrane, decreased mobility of tympanic membrane, purulent fluid in middle ear)
PLUS
Evidence of middle ear inflammation
Otitis Media with Effusion (OME)
Fluid in middle ear without evidence of local or systemic illness
Recurrent AOM
> =3 episodes of AOM within 6 months OR
4 episodes within 1 year with 1 episode in past 6 months
When immediate antibiotic therapy warranted for AOM
Bulging tympanic membrane, perforation, otorrhea
Delayed antibiotic prescribing for AOM
> 2 y/o without severe systemic symptoms
or 6mo-2 year if mild and unilateral
Treat only if:
-oltagia x48-72 hours
-temp >102.2F in past 48 hr
Analgesics for otalgia recommended (more beneficial than ABX)
OME treatment
Antibiotics not generally given b/c will spontaneously resolve
Only give if bilateral effusion for more than 3 months
Do not give steroids, antihistamines, or decongestants
First line AOM antibiotics
Amoxicillin 80-90mg/kg/day divided BID
If amox given in past 30 days, give augmentin 14:1
PCN allergy: cefdinir, cefuroxime, cefpodoxime, ceftriaxone (50mg/kg daily x3 days)
If treatment failure can consider clindamycin 10mg/kg q8h +/- 3rd gen cephalosporin
AOM duration
< 2y/o or severe: 10 days
2-5 with mild-moderate symptoms: 7 days
>=6 y/o with mild-mod: 5-7 days
PCV notable change in pediatric immunization schedule
PCV7 replaced by PCV13
PCV15 is alternative to PCV13
PCV20 likely to be included in 2024
HPV notable change in pediatric immunization schedule
HPV4, Gardasil approved for 9-26 y/o
males: prevent genial warts
females: prevent genital warts, cervical, vulvar, vaginal, anal cancer
LAIV notable change in pediatric immunization schedule
Reassess every year if appropriate
Do not give <2 y/o
Do not give <4 y/o with asthma
Caution if >5 years with asthma
MMR & Varicella preference
ACIP prefers separate MMR and Varicella vaccine for first dose d/t higher incidence of febrile seizure
second dose can be proquad or separate
Immunizations containing neomycin
Inactivated polio vaccine
MMR
varicella
Immunizations contraindicated if recent IVIG
MMR, varicella
Contraindication to DTaP
Encephalopathy within 7 days after administration
Rotavirus contraindication
Hx of intussusception
where to report vaccine product concerns
Vaccine Adverse Events Reporting System (VAERS)
Steroids and live immunizations
Okay to administer if <2mg/kg/day of prednisone equivalent
Can be given immediately after finishing >=2mg/kg/day for less than 14 days
Delay 1 month after completing >=2mg/kg/day for>=14 days
Common comorbid conditions with ADHD
Oppositional defiant disorder (most common)
Anxiety
Tics
Preferred first line ADHD treatment
Methylphenidate or Amphetamine
Try both before deeming treatment failure
Both may exacerbate tics - use w/ caution
Amphetamines and sudden cardiac death
No CAUSATIVE relationship between amphetamine and SCD.
If known structural heart defect, do not use amphetamine
Otherwise, okay to use, can monitor with EKG but not necessary.
ADHD recs for children 4-5 y/o
1st line: behavior therapy
2nd line: methylphenidate
ADHD recs for children 6-11 y/o
1st line: amphetamine or methylphenidate plus behavior therapy
Can consider non-stimulant, but evidence weaker
ADHD recs for 12-18 y/o
1st line: any FDA approved medication, stimulant or nonstimulant
Can consider behavior treatment
Atomoxetine
FDA approved Norepinephrine Reuptake Inhibitor (nonstimulant for ADHD)
-First line for children with substance abuse, comorbid anxiety, or tics
2D6 metabolism
BBW: increased risk of suicidal ideation
Potential for liver toxicity (no monitoring required)
Consider for children 6-11y/o (stimulant first line) preferred second line agent after stimulants
First line option for 12-18 y/o
Viloxazine ER
FDA approved Norepinephrine Reuptake Inhibitor (nonstimulant ADHD)
May induce manic episodes
May increase HR, BP, somnolence, fatigue
BBW: increased suicidal ideation
Potential liver toxicity (no monitoring required)
Consider for children 6-11y/o (stimulant first line)
First line option for 12-18 y/o
Antidepressants for ADHD
Non-FDA approved
Bupropion
TCAs (imipramine, nortriptyline) – EKG needed at baseline & with dose increases
Clonidine ER
FDA approved alpha-adrenergic receptor agonist for ADHD (nonstimulant)
-More effective for hyperactivity than inattentiion
-LESSENS severity of tics (especially when used w/ methylphenidate)
-Causes sedation
Consider for children 6-11y/o (stimulant first line)
First line option for 12-18 y/o
Guanfacine ER
FDA approved alpha-adrenergic receptor agonist for ADHD (nonstimulant)
-Improved comorbid tic disorder
-Less sedating than clonidine
-Rebound HTN
Consider for children 6-11y/o (stimulant first line)
First line option for 12-18 y/o
Longest acting stimulat
Mydayis (mixed amphetamine salts ER) up to 16 hours
