Exam Two Study Guide
Gastroenteritis- Children under 5 most affected. Gastroenteritis in the pediatric population is a very
common condition that accounts for around 10 percent of pediatric deaths and is the second cause of
death worldwide. The most common cause in infants younger than 24 months old is rotavirus, and after
24 months of age, shigella becomes the most common cause and rotavirus the second most common.
This activity reviews the evaluation and treatment of pediatric gastroenteritis and highlights the role of
the interprofessional team in evaluating and treating this condition.
Pyloric Stenosis Gastroenteritis occurs when there is a fecal-oral contact, ingestion of contaminated
water or food and person to person, been this the most common way of acquiring this infection and
making it the main cause for norovirus and shigella outbreaks. This disease is associated with bad
hygiene and poverty.
In the United States, rotavirus and noroviruses (accountable for almost 58% of all cases) are
the most common viral agent that causes diarrhea, followed by enteric adenoviruses, Sapovirus,
and astroviruses.
The main risk factors for gastroenteritis are environmental, seasonal, and demographics, being
you children more susceptible. Other diseases like measles and immunodeficiencies put the
patient at a higher risk for a gastrointestinal (GI) infection. Malnutrition is another significant
risk factor, like vitamin-A deficiency or zinc deficiency.
Most of the episodes are acute diarrheas, lasting less than one week. When diarrhea lasts more
than 14 days, it is considered persistent diarrhea and accounts for 3% to 19% of episodes.
Around 50% of death cases due to diarrhea.
Parasites- Fecal-oral contact with eggs
Cysts excreted into contaminated food or water
Larvae from walking barefoot on contaminated soil
Poor sanitary disposal of human waste into soils
Most transmission can be prevented by good hand washing and good sanitation
Prevention: eat peeled or cooked foods; wear shoes; drink or brush with bottle water
GERD- Reflux with symptoms/complications. Associated with irritability and secondary problems i.e.
injury to esophageal mucosa, extra- esophageal disease, aspiration pneumonia, failure to thrive,
esophagitis, Sandifer Syndrome (abnormal posturing of neck and head). May have wheezing/respiratory
symptoms with aspiration. Abdominal and Neurological exam are normal.
With FTT note that weight is first affected, then height and finally head circumference
enamel erosion, and wheezing associated with GERD- Often caused from overfeeding or incomplete
burping, GER is reflux of gastric contents into esophagus as a result if immaturity of lower esophageal
sphincter; normal physiologic process that occurs throughout the day in healthy infants, children and
adults; GER occurs during periods of transient relaxation of the lower esophageal sphincter.
Tests for: Diagnosis often made by observation and history.
24-hour pH probe – valid and reliable but may be normal in some with disease. Can distinguish between
acid and nonacid reflux. Upper GI, endoscopy, guaiac stool or emesis may be positive.
Intussusception- Surgical emergency-proximal small bowel telescopes into distal colon-intermittent
presentation with- vomiting, colicky pain, guarding, drawing up knees, currant jelly stool, abdominal
distension, ages 3 mo -3 years
Telescoping of one part of bowel into other 2-4/1000
Most commonly occurs 5-10 months of age
Most common cause intestinal obstruction 5 months – 3 years of age
Acute, intermittent, colicky abdominal pain, with vomiting every 5-30 minutes, with periods of sleep
and/or lethargy in between
Late symptoms: fever, characteristic “current jelly stools” (in 50% of intants) bilious vomiting
Diagnosis: Call surgeon immediately if suspect. NPO, IV, IV antibiotics. May be able to be reduced via
air constrast enema under fluoroscopy
Surgery if interventional radiology procedure does not resolve
Appendicitis- Most common in children 6-14 years of age with peak at ages 9-11 years
Males>females; more autumn and spring
Vague, possibly midline, constant abdominal Pain is earliest symptom. Precedes anorexia, nausea or
vomiting. Diarrhea, if present, is low volume with mucus but child can be constipated. Vomiting, if
present, is usually limited
Anorexia or nausea common, if hungry it isn’t likely to be appendicitis
Low grade fever is common
Periumbilical pain early on > worsens > migrates to RLQ Child walks bent over and lies with knees up on
abdomen
Perforation
Tests: CBC unreliable but necessary, ultrasound vs CT
Guarding
Rigidity – involuntary reflex spasm in response to peritoneal inflammation
Rebound tenderness in RLQ with intense pain at McBurney’s point, halfway between umbilicus and
anterior superior iliac crest.
Psoas sign – RLQ pain w/right hip extension while lying on L side
Obturator sign – RLQ pain w/flexion & internal rotation of R hip
Rectal exam – Tenderness and/or palpable abscess RLQ
The “jump down from the table” test will elicit pain
Rovsing’s sign – pain RLQ with left-side pressure; highly indicative of appendicitis.
CBC: elevated WBC with mild leukocytosis and left shift, normal doesn’t exclude
Urinalysis: to r/o UTI, assess hydration
Electrolytes if vomiting significant
CT most sensitive and specific; Ultrasound is often done first because it is quicker and minimizes
radiation exposure.
Ultrasound if ovarian condition part of differential.
Radiography of abdomen to rule out constipation.
Hepatitis- inflammation of liver, can damage liver cells,
• Hepatitis viruses. There are 5 main types of the hepatitis virus: A, B, C, D, and E.
• Cytomegalovirus. This virus is a part of the herpes virus family.
• Epstein-Barr virus. The virus causes mononucleosis.
• Herpes simplex virus. Herpes can affect the face, the skin above the waist, or the genitals.
• Varicella zoster virus (chickenpox). A complication of this virus is hepatitis. But this happens
very rarely in children.
•
Enteroviruses. This is a group of viruses often seen in children. They include
coxsackieviruses and echoviruses.
• Rubella. This is a mild disease that causes a rash.
• Adenovirus. This is a group of viruses that causes colds, tonsillitis, and ear infections in
children. They can also cause diarrhea.
Parvovirus. This virus causes fifth disease. Symptoms include a slapped-cheek rash on the face
Hirschsprungs- Absence of intramural ganglion cells of submucosal and myenteric plexus from distal
rectum to variable length proximally
1:5000 births, 4:1 male
60% diagnosed within 1st 3 months
Failure to pass first meconium within first 24 hours of life
Constipation, abdominal distension, vomiting, FTT
Urge to defecate may be absent (no withholding behaviors/postures)
Rectal exam: rectal vault empty
Diagnosis: BE not useful; refer for manometry or biopsy
Treatment: surgical resection of aganglionic segment
small, ribbon-like stools; no leakage or no stools. Empty rectum, palpable abdominal mass, explosion of
stool upon withdrawal of examining finger, guaiac positive, abnormal bowel sounds, abdominal
distension.
Irritable Bowel Disease- Rome II Diagnostic Criteria
Abdominal discomfort or pain associated with: improvement with defecation, change in frequency of
stool, change in form or appearance (floats on water)
Psychological co morbidity incudes anxiety and depression
Bloating, dyspepsia, family history of IBS
Avoid caffeine, sorbitol, fatty food, carbonated beverages, lactose, cruciferous vegetables, gas-producing
foods.
Give fiber, probiotics, peppermint oil, antispasmodic agents, antidiarrheal agents, antibiotics,
amitriptyline or serotonin reuptake inhibitors.
Cognitive behavioral therapy, yoga, acupuncture, hypnotherapy
Celiac Disease-autoimmune GI disorder related to eating gluten. Causes immune response, damaging
intest. Villi.
Functional abdominal pain- Fecal calprotectin is a good initial test also- Management could include
having a bland diet, lactose free diet, avoid artificial sweetners, use mind-body approach combining
relaxation, behavioral management, stress coping training, meditation, and biofeedback. Acupuncture,
massage and hypnosis.
Constipation- Functional: most common. Functional fecal retention/holding, dietary change, routine
change, toilet training, stressful events, intercurrent illness, “too busy to go”, etc. A cycle of stool
holding and painful stools leads to more constipation leading to impaction and encopresis.
Obstructive: anteriorly displaced anus, anal stenosis (congenital or acquired),
Meconium ileus, cystic fibrosis, post-infectious or post-op stricture, tumor
Neurologic: i.e. Hirschsprung, botulism tumors, spinal injury, myelomeningocele
Endocrine: Hypothyroid
Medicinal: laxative abuse, diuretics, tricyclic antidepressants, narcotics, aluminum antacids, iron
Encopresis: soiled underwear, may appear to be diarrhea; may occur daily. May have impacted stool,
normal tone, abdominal distension with sausage shaped mass in left pelvis or midline
DERM- Chapters =
Erythema Toxicum Neonatorum-benign self limiting, macules and plaques 2-3 cm with 1-3mm central
vesicle, usually found during the first week of life on trunk and extremities.
Steroids- injections to treat inflammatory acne lesions
Newborn lesions- The main lesions described as typical of the neonatal period include
erythema toxicum neonatorum (ETN), transient neonatal pustular melanosis (TNPM)- show
predominance of neutrophils and benign cephalic pustulosis (BCP). These are a benign, selflimited, asymptomatic skin diseases that occur in the first days of life.question
herpes- painful, will coalesce, multineucleated giant cells in Tzanck smear. if unsure of lesion always give
azithromycin
Milia – small lesions 2-3mm over neck groin or axilla
Pityriasis-occurs in fall and early winter Occurs in fall and early winter
Seen in adolescents
Begins with herald patch and then small m-p rash appears on trunk in Christmas tree pattern on back
Itching occurs 25% of time
Oral lesions in 16% patients
Application of calamine lotion
Minimal sun exposure
Treat with Oral erythromycin- Alba- dry scaly hypopigmentation, initially red scaly patch, round or oval ,
treat with moisturization
Pityriasis rosea- single oval lesion called herald patch with peripheral scale, clears in 6 weeks, rash is
usually along rib line with Christmas tree appearance- if irritated treat with 1%topical hydrocortisone
Eczema- itching lesions usually found on AC and popliteal fossa . skin becomes thicker over time
(lichenification). Rubbing and scratching make it worse. Treat with bath oil, soap substitute, topical
steroids 1% and antihistamines.
Melanoma- Nevi may become melanoma (melanocytic nevi), look for Asymmetry Boarder Color DEs
Psoriasis- treat with occlusives, warm baths and pat dry. May also use wet dressings, steroid creams
• Common, chronic, recurrent, genetic predisposition, cause unknown
• Small papular lesions with small silvery scales
• Treatment - bland ointments, stronger (flouridated) topical corticosteroids and coal tar
preparations for thickened lesions and scalp, ultraviolet light. Treatment similar to Seborrhea
Toxic Epidermal Necrolysis (TEN)- Most severe, drug-induced or infection
• Extensive epidermal loss due to necrosis, greater than 30% of epidermis, looks like scalded skin
• Leukopenia, high fever, extensive lesions in respiratory and GI tract
• High morbidity – 25% to 30%
• MEDICAL EMERGENCY!!
Contact dermatitis- itching and rash due to contact with substance or clothing, non fragranced soaps,
antihistamine, shower, non irritating soaps
Allergic or irritant
Symptoms - itching, burning, stinging, macular/papular rash
Differential: eczema, drug rash, urticaria
Treatment: topical and systemic steroids, antihistamines
• Prednisone dose pack for 2-3 weeks : 1 mg/kg/day 12-21 days
Mild cases will go away on own eventually
Seborrhea dermatitis- Inflammatory condition usually on sebum-rich areas such as the scalp and face
Cradle cap in newborn
Dandruff in adolescents
Erythema under yellow crusts and greasy scales on scalp, face, neck folds, postauricular, and axillary
creases
No tests to confirm
Shampoo and wash affected areas with a nonperfumed baby shampoo or baby wash; for adolescents
use antiseborrheic soaps and shampoos
Mineral oil with brushing to loosen crusts prior to washing
Topical steroid lotions for extreme cases to reduce inflammation
Burn- calculation- degrees of burns- rule of nines Degrees of burn injury
Superficial/Partial thickness and full thickness burns
1º, 2º, and 3º
Wound management –
patient to return to office daily for dressing change, consider families ability to care for burn wound
tetanus prophylaxis, mupirocin for minor burns ≤ 5 days
Criteria for hospital admission
Referral/consult - full thickness burns, partial thickness 10% or greater; burns to face, hands or greater
than 1% of BSA
Electrical and chemical burns - emergency
SUN Burn- Thermal burn due to excessive sunlight exposure
• Factors include high altitude, nearness to equator, and exposure to sun during hours of 10 a.m.
to 3 p.m. when UVB waves are strongest
• Redness, swelling, blisters, tenderness of areas, fatigue, chills, and headaches
• Remove from sun, cool water to area, oral fluids, pain medications, topical emollients for dry
skin, sunscreen 20 minutes before exposure
Folliculitis-inflamed hair follicle- hair follicle) usually staph, ingrown hairs, inflammatory. Itching and
burning, erythema, papulo/pustule•Differential - boil, impetigo
(Hot tubs)•good hygiene, topical
antibiotics, hot cloth
Herpes- treat with acyclovir Primary and secondary infection
– Oral, vulva or anywhere on skin
– Painful, vesicular
– Recurs with trauma, stress, sun exposure/tanning beds, fever
– If near eyes, refer immediately
Impetigo- crusty honey colored usually staph or strep. Treat with mupirocin
Molluscum contagiosum- Common, DNA pox virus; single to multiple white, flesh-colored or pink
papules that may be dome, resolves slowly, usually on face or extremities but may also be on genitals
and not due to abuse!
Child may autoinoculate
Differential: warts, acne, milia
Diagnosis: appearance, slide for inclusion bodies by Wrights stain
Treatment: resolves spontaneously and usually needs no intervention; surgical removal or curettage,
cryosurgery, trichloracetic acid - these treatments may cause scarring
Tinea-fungal tinea corporis, tinea capita, tinea, usually caused by dermatophites Microsporum canis and
Tricophyton tonsurans.
Scabies- found at wrist, hand boarders, sides of fingers and webs. Tracks with brown spots at the end
permethrin 5%- treat whole family , wash clothing, linens, antihistamines for itching
Pediculosis (capitus)- head lice, may be due to overcrowiding and poor hygiene, treat with 15
permethrin, or 0.5% malathione on scalp for 12 hours then washed off.
Erythema multiforme minor -hypersensitivity reaction- itching and pain. Lesions progress, rule out
pneumonia herpes, cool compress for pain, anithistamines. can be due to a reaction to food, medication
or virus. Does not progress to SJS round with blister in center , usually due to HSV. Treat with acyclovir
Acne- chapter 135 page – due to increased androgen secretion, and enlargement of sebaceous glands
and increased sebum production. Can scar and cause hyperpigmentation in darker skinned. (XYY
Klienfelters syndrome) androgens and steroids make worse – treat with topical retinoid , benzoil
peroxide OTC, may need topical antibiotic or oral antibiotic , oral steroids and contraceptives
Vititligo – Auto immune disease, treat with UV light and topical steroids
Caput succedaneum- scalp edema that crosses suture line and may be ballotable, usually resolves
rapidly
Cephalohematoma-subperiosteal bleed that does not cross the suture line, may take 2 months t
resolve. May be associated with skull fractures
Respiratory /HEENT
Consider: Age, season, contacts, daycare, travel, animal exposure, environment (heat, ETS exposure,
etc), vaccination status
General : Respiratory distress? Ill appearing? Toxic appearing?
HPI: symptoms, duration, progression, fever, effect on activities and appetite, treatment tried*
ROS: Associated symptoms – Eyes, headache, ENT, upper and lower respiratory, GI, cardiac, urinary
output
PMH
FH
*When exploring treatments tried at home be sure to ask about complementary/alternative therapies
and convey respect and tolerance
Croup- Laryngotracheobronchitis (LTB)- Involves larynx, trachea,
upper
bronchioles
6 months – 6 years (peak 6-36 mos)
Fall and early winter
Viral illness (75% parainfluenza)
Inflammation and edema causse classic symptoms of hoarseness, barky cough, inspiratory stridor
S&S last 5 days, worse at night, peak at 24-48 hr, May have low grade fever, runny nose before croup
S&S
Differential: epiglottitis, foreign body, tumor or malformation
Consider: 1) Age (the younger/smaller the more risk of distress). 2) Day of illness. 3) Degree of stridor at
rest.
4) Time of day – when will steroids to kick in?
Dx: Usually based on clinical findings
Labs: Oximeter reading (typically WNL), x-ray prn
Tx: Steroid (oral, single dose; inhaled, IM), hydration, close monitoring. Sometimes: racemic epineph
(hosp setting only)
Oral steroids begin to work within 2 hours
NO antibiotics
Problems – use of nose spray for too long? Emergency treatment is to sit upright, learn forward and
press nares together at bony structure. For 10-15 minutes. Use bedside humidifier and apply topical
antibiotic to site of scab for 2 weeks Silver nitrate sticks, nasal packing, and neo synephrine 0.25% can
be used to stop the bleeding. Always check blood pressure.
Spasmodic croup does not have fever, occurs in early morning hours and occurs in a well child. Family
history is positive.
Epistaxis- Problems – use of nose spray for too long? Emergency treatment is to sit upright, learn
forward and press nares together at bony structure. For 10-15 minutes. Use bedside humidifier and
apply topical antibiotic to site of scab for 2 weeks Silver nitrate sticks, nasal packing, and neo
synephrine 0.25% can be used to stop the bleeding. Always check blood pressure.
Retropharyngeal abscess- A progressively severe sore throat on one side and pain during swallowing are
earliest symptoms. As abscess develops persistent pain in the peritonsillar area, fever, sense of being
unwell, headache, and a distortion of vowels known as “hot potato voice”. Neck pain associated with
tender swollen lymph nodes, referred ear pain and foul breath are also common. Consider this if person
has limited ability to open their mouth. The uvula may be displaced towards the unaffected side.
Strept, staph and hemophilus are causative agents. Treatment is I & D, antibiotics with clindamycin or
metronidazole in combination with penicillin G. If recurrent may be candidate for tonsillectomy. It is
life threatening if untreated. Retropharyngeal abscess more common under 6 yrs and peritonsillar
abscess more common from 20-40 years.
Cystic Fibrosis- Multisystem genetic disorder manifested by chronic obstructive pulmonary disease
It is an autosomal recessive genetic disorder more common in Caucasians.
Main problem is mucus thickening and target organ damage in lungs and exocrine glands (sweat
glands – taste salty, biliary tree, pancreas (diabetes), intestines, vas deferens – decreased
fertility).
Pulmonary-infections both viral and bacterial to respiratory failure
GI tract and nutrition – meconium ileus, pancreatic enzyme deficiency, hypoproteinemia
(edema), steatorrhea, intussusception, rectal prolapse, biliary fibrosis, hepatic steatosis.
Volvulus, GERD, poor fat absorption (anemia, night blindness, neuropathy, osteoporosis, and
bleeding disorders.
Pulmonary – inhaled dornase alfa (recombinant human deozyribonuclease)
Postural drainage, active cycle of breathing, autogenic drainage, percussion, positive expiratory
pressure, exercise, and high-frequency chest wall oscillation are done twice a day
Ivacaftor (Kalydeco to potentiate CFTR)
High dose ibuprofen and oral azithromycin three times a week to reduce chronic airway
inflammation. Must be screened prior for mycobacterial infection. Check for GI bleeds however
Hemoptysis associated with advancing disease and vitamin k deficiency
Watch for pneumothorax (acute onset of pain and dyspnea)
Pancreatic enzymes lipase 2000-10,000 units/kg/day
Replacement of fat soluble vitamins A, D, E and K
Ursodeoxycholic acid is recommended due to liver disease CFLD
Distal intestinal obstructive syndrome (DIOS) is managed with osmotic laxatives
Screen for diabetes with oral glucose tolerance test at age 10
Insulin is used to treat CFRD (cystic fibrosis liver disease)
Distal intestinal obstructive syndrome –viscous fecal matter blocks distal intestine
TB- CA, TX, NY, IL, GA, FL = 2/3 of pediatric TB cases
• Worldwide 1.5 million deaths from TB in 2011
• PPD testing is not universal in all areas
• Do test: All foreign adoptees, all in/from endemic areas, contact with known positive or at-risk
individual, immigrants, travel to endemic country, HIV, immunosuppressed, incarcerated
individuals
• Hx of BCG vaccine is not a contraindication to screening
• Stages of TB
• Exposure
No S&S, negative PPD
• Latent
No S&S, positive PPD
• Disease
S&S, positive PPD, radiographic evidence
• Most children get infection from adult
• Most m. Tuberculosis infections in children are asymptomatic
• May present 1-6 months after infection with fever, weight loss or growth delay, cough, night
sweat, chills.
• Extrapulmonary symptoms may include meningitis, granulomatous inflammation of lymph
nodes, bones, joint, skin, middle ear, mastoid
• Lymph nodes = gradual enlargement, firm, fixed, unilateral.
• Disseminated TB more likely in infants = lymphohematogenous spread to brain (TB meningitis
esp in children < 1 yr of age), growth plates of bone, and lymph nodes
• Exposed, tuberculin-negative children may be treated. Contact your local health department for
advice
• Skeletal tb may go unrecognized for months to years. It affects spine most often.
•
Asthma- Most common chronic childhood illness and most common diagnosis for children admitted to
the hospital
7.1 million children affected (2009 data). Increasing incidence
1/3 present in first yr, 80% by school age
Not usually diagnosed < 2-3 years of age
4th most common reason for ER visit by children
Average 174 deaths/year in children < 17 yr
compared to > 3,000 adult deaths per year
(2005-2007 data)
10.5 million lost school days each year
There are definite connections between allergic rhinitis, sinusitis, and asthma, and probable
connections with GERD
40-80% of children with asthma have at least one positive allergen skin test
Allergy is a major predictor of persistence of asthma with age
Multifactorial: environment, family hx, etc
Studies show children can accurately report on their symptoms
7-11 year olds: provided “valuable information”
>11 years old: parents provided
little or no additional info Even 6 year olds can provide information that is “adequately reliable”
Chronic mouth breathing
Risk factors: family history, tobacco exposure, house dust mites, cockroach antigen, high indoor
humidity, outdoor pollution Strong evidence of copicated neurogenic reflex that exacerbates
asthma when uri symptoms present
Assessing a Child With Asthma
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May need to do a rapid HPI and treat immediately
Assess what has been tried at home. Be aware of home treatment failures due to
things i.e. empty MDI canisters
Thorough HPI, PMH, and FH
LOOK – with entire chest uncovered
Count respirations yourself & document findings
Watch for respiratory effort
Listen to respiratory noises with and without stethescope
Get oximeter reading
Administer bronchodilator prn and then reassess everything again
PFTs 1-2 times per year for all with persistent asthma who need daily antiinflammatory treatment
Goal of Therapy: Control Asthma
•
Reduce impairment
Prevent chronic symptoms
< 2 days a week need for SABA
Maintain normal or near normal lung function
Maintain normal activities
Meet families expectation and satisfaction with care
• Reduce risk
Prevent exacerbations, minimize ER visits/hospitalizations
Prevent loss of lung function; for children, prevent reduced lung
growth
Optimal pharmacotherapy with minimal/no adverse effects
Medications
Corticosteriods: Mainstay of Rx. Daily inhalation form if in any persistent classification. Oral x 310 days if severe flare
Mast Cell Stablilizer: Cromolyn. Nedocromil. Safe. Requires at least TID dosing. Inhaled only.
Affects late phase reactions
Leukotriene Modifiers: Singulair (only one for kids). Both anti-inflammatory and bronchodilator.
Adjunct therapy. Can reduce prn albuterol use by 33% and steroid use. May help with upper
respiratory allergies. Safe. QD dosing. Use in 2 yr and up. Useful with exercised induced.
Antibiotics?? NO, unless concurrent infection present
Introcuction of ICS at time of diagnosis does most to prevent permanent airway remodeling
Sterioid bursts for 3-10 days. 1-2mg/kg/day, bigger kids closer to 1/kg/day with 60/day max
Consider side effects of long term or recurrent bursts: ostgeoporosis, growth, cataracts, adrenal
insufficiency
Oral candidiasis, dysphonia with inhaled: rinse mouth 4-6 bursts/yr -> increased problem side
effects
Address steroid phobia with parents
Short acting B2 Agonists – Albuterol (po, inhaled). Xopenex (inhaled). Parents should know
these as “rescue/emergency” medications. Also used for exercised induced asthma
Long Acting B2 Agonists: Serevent (>4 yr), Foradil (>5 yr). No anti-inflammatory effects.
Indication for exercise induced asthma & maintenance, but not 1st line for maintenance. Rx by
subspecialist only. Note: All LABA, alone or in combination, have black box warnings.
Combination: i.e. Advair Diskus (Serevent + Flovent) > 4 yr; Advair HFA for > 12 yr, Symbicort
(Foradil +budesonide) for > 12 yr
Methylxanthines: Theophylline
Inhaled: use albuterol before steroid
epiglottitis- Causative organism is haemophilus influenzae type B. Occurs in children between 1 and 5
years of age.
Abrupt onset of fever, severe sore throat, dyspnea, inspiratory distress without stridor and drooling.
Child looks acutely ill and toxic. Flaring of ala nasi and retraction of supraclavicular, intercostal and
subcostal spaces.
Sits in tripod position with arms back, trunk forward, neck hyperextended and chin thrust forward.
Stridor irritability, restlessness and brassy cough. A “thumb” sign on xray rules in the condition.
What two things should you do if you suspect this?
Don’t lay them down and transport via emergency medical services to the hospital. Time from onset to
death brief. Will need trach or airway. Iv antibiotics to treat H.flu. Treat household contacts
Bronchiolitis- Viral illness that affects bronchioles. Freq caused by RSV
By definition bronchiolitis affects children < 2 years (peak age 3-6 months)
Incubation 4-6 days. Source of infection may be older contact with mild URI symptoms.
Virus enters nasopharynx, replicates, spreads to lower respiratory tract
Virus causes necrosis and sloughing of epithelium, airway edema, and increased mucous -> increased
airway resistance, hyperinflation, ventilation: perfusion mismatch, atelectasis, hypoxemia.
Common diagnosis used for an infant with wheezing for the very first time and is the leading cause of
hospitalization for infants.
Predominately caused from Respiratory Syncytial Virus.
Normally seen from November through March with no outbreaks in summer.
Spread by close contact with infected respiratory secretions of fomites – can live for 30 minutes on
surfaces – most spread by hand carriage of secretions
Source of infection is older person with a mild URI
Most cases resolve completely
Children who have compromised respiratory and cardiovascular systems most prone
Prolonged apnea and inability to drink causes of death 1-2%. Has been associated with development of
asthma. Palivizumab (Synagis) is an RSV-specific monoclonal antibody used as protection against RSV. It
is dosed once a month by IM injection throughout duration of RSV season.
All children have RSV by 2nd birthday. 20-30% progress to lower resp symptoms with first infection.
75-90% children < 2 y.o. hospitalized with bronchiolitis have RSV
Typically occurs November – March
URI progresses to wheezing, tachypnea, cough, otitis (10-30%), low-mod grade fever. Apnea is severe
complication in young infants
Subjective Hx: ability to eat & sleep, detailed intake, output, level of fatigue, etc
Objective: complete exam with thorough respiratory system assessment including O2 sat, resp rate &
effort, color, cap refill. MUST undress from waist up and observe! R/O pneumonia and sepsis
Very contagious, avoid contact especially with infants
Labs: oximetry always, consider CXR. Rapid test for RSV has good sensitivity and specificity but need to
use is controversial
Treatment is supportive: hydration, nasal suction, O2 prn. Bronchodilators not routine. Steroids not
indicated. Antibiotics only if secondary infection. No antiviral avail
Hospitalization? Consider age, RR (>50-60 at rest), PMH, degree of resp distress, ability to eat, LOC,
oxygen levels, hydration, parents’ ability to comfortably & safely monitor
Follow very closely, esp little ones. Hospitalize prn
epistaxis- Problems – use of nose spray for too long? Emergency treatment is to sit upright, learn
forward and press nares together at bony structure. For 10-15 minutes. Use bedside humidifier and
apply topical antibiotic to site of scab for 2 weeks Silver nitrate sticks, nasal packing, and neo
synephrine 0.25% can be used to stop the bleeding. Always check blood pressure.
Thrush- White plaques on buccal mucosa, tongue, inner lips that can not be wiped off due to a fungal
infection.
Irritating, may affect feeding
Rx: Oral - Nystatin swab to affected area, Diflucan po if nystatin ineffective
Education: sterilize pacifiers, etc. Watch intake.
Whitish patches on tongue and red satellite lesions on diaper area. As compared to diaper rash due to
irritation this diaper rash is glistening, not dry.
If oral thrush found, look at bottom.
herpangina- Herpangina: Coxsackie A virus (some others as well). Vesicles -> ulcers primarily posterior
pharynx, spares gingiva and buccal mucosa. Abrupt fever, may be high, headache, myalgia, malaise,
dysphagia, vomiting, anorexia, oral discomfort and drooling. Seen commonly in children under 5 years.
Summer. Vesicles, punched-out ulcers present tonsillar pillars, uvula and soft palate. Anterior structures
like gingiva, buccal mucosa, and hard palate not affected. Average 2 -12 lesions. Topical relief with 1:1
mixture of diphenhydramine combined with antacid preparations consisting of magnesium and
aluminum hydroxide or antidiarrheal preparations to provide protective coating for the oral mucosa.
Severe cases might need 2% viscous lidocaine added; use sparingly.
Hand foot mouth disease
Acute viral illness presenting with vesicular exanthem on tongue, tonsils, gums, hard palate, oral
mucosa; papulovesicular exanthem on hands, feet, and commonly the buttocks in diapered children;
less commonly may occur on the trunk and extremities. Vesicular lesions appear as blanching red lesions
on anterior pillars, palms and soles, less commonly on trunk and extremities. Coxsackievirus A16 is the
most common causative agent. Low grade fever, anorexia and dysphagia. Cold liq, popsicles, bland diet
as tolerated. Do not worry if does not eat, do worry about fluid intake
Rx: Antiviral (acyclovir) for Gingivostomatitis only, if severe. Dose 20 mg/kg per dose QID
Educate parent. Long course. Highly contagious. Watch hydration status. Avoid contact with
immunosuppressed individuals, newborns, etc
Similar to Herpangina but with exanthum
Coxsackie A virus (a type of enterovirus)
Mainly in summer
Vesicles -> ulcers on anterior pillars, soft palate, uvula; abrupt fever in 101 range; rash on palms and
soles
Cleft lip and palate- Defects occur early 1st trimester
Wide range of degree of malformation.
Do careful examination of mouth
and pharynx of all newborns.
Defects of soft palate can be subtle
In USA, annually, over 2600 born with cleft palate and 4400 with cleft lip (+ cleft palate). 70% isolated
(not associated with other birth defects).
Assess for other associated abnormalities, consider syndrome
Refer to cleft lip/palate center if available
Common co-morbidities: Feeding, speech, dentition, otitis media, hearing problems secondary to AOM,
sinusitis
Cleft lip repair at 2-4 months of age
(“10 pounds, 10 weeks, Hgb 10”)
Cleft palate repair 6-18 months of age
May need surgical revisions later in life
Consider psychosocial needs of child and family
For more information about cleft lip, cleft palate, or otoplasty go to http://www.plasticsurgery.org and
do search of cleft lip and palate
Want to repair before speech if possible
Otoplasty at 5 years or when ear cartilage is stable
Conjunctivitis- Bacterial – bilateral, minimal itching, moderate tearing, profuse exudate, exudate
purulent, eyes matted shut in a.m., preauricular nodes uncommon, occasional sore throat or fever, 2-3
day incubation, may be assoc with otitis. Same organisms as in otitis media. NL vision
Viral – more likely unilateral initially, profuse tearing, less exudate, exudate more mucoid, preauricular
nodes common, may be associated with rash, sore throat, fever, 5-14 day incubation
Allergic: red, itchy, watery, seasonal
Good Handwashing
Viral: self-limited
Bacterial: self-limited but treat to prevent spread and shorten course. Most often gram positive.
Rx: antibiotic ophthalmic drops. Parent education Allergic: Ophthalmic drops (decongestant,
antihistamine decongestant, or mast cell stabilizer). School: “Except when viral or bacterial conjunctivitis
is accompanied by systemic signs of illness, infected children should be allowed to remain in school once
any indicated therapy is implemented, unless their behavior is such that close contact with other
students cannot be avoided.” Refer to ophthalmologist: pain; vision change; persistent photophobia;
cornea is not clear; vesicular lesions near eye; abnormal EOM, vision, or pupillary response
Consultation and/or referral: History of trauma/foreign body, extremely red rather than pink, high
fever, systemic illness, refusal to use or open eye
See all newborns, infants, & children < 2-3 years and any child who is not improving by 48-72 hours after
treatment initiated, or whose symptoms worsen before that time
Newborn conjunctivitis
Reaction to erythromycin – resolves spontaneously in days
C. trachomatis: appears in 1-2 weeks, 50% with pulmonary symptoms, Rx systemically
N. gonorrhea: is reason for prophylaxis with erythromycin at birth (1% failure rate). Incubates 3-5 days,
Rx IV antibiotics
HSV – Systemic symptoms. Incubation 3 days – 3 weeks. Tx: topical and systemic antibiotics.
Goal: Prevention of blindness and consequences of associated systemic disease i.e. neurological
impairment from HSV Culture conjunctival exudate on all < 1 month
Consult/refer all newborns (1 month or less of age) who have conjunctivitis
Hordeolum
(Stye): staph in sebaceous (external hordeolum) or meibomian glands (internal hordeolum) of eyelid.
Tender, swollen, red furuncle; typically on the lid margin or on the conjunctiva. It may suppurate or
drain spontaneously. Tx: warm compresses for 15 minutes 3-4 times daily. Antibiotic ophthalmic
ointment or drops that treat staph species: Sulfacetamide sodium 10%, polymyxin B-bacitracin, or
erythromycin ophthalmic ointment. Cleanse eyelids with diluted baby shampoo once a day. Refer for
incision and drainage if unresponsive to treatment after 2 weeks. Dispose of old eye makeup;
discourage use of eye makeup until hordeolum is resolved; stress good hand and eye hygiene. Do not
wear contact lenses until resolved.
Blepharitis
• orbital cellulitis- Orbital: Infection of the soft tissues of the orbit posterior to the orbital septum.
May involve the extraocular muscles and optic nerve; does not involve the orbit. Orbital
• Common older children
• Sinusitis is source often
• Life-threatening and vision-threatening complications may occur and include brain abscess,
cavernous venous thrombosis, orbital abscess, retinal detachment, and optic neuropathy
• Requires hospitalization
Periorbital: Inflammation/infection of the skin and subcutaneous tissue surrounding eye. Common
younger children
Commonly associated with skin diseases of the eyelid or face such as insect bites, impetigo, styes; can
also occur as a result of an extension of sinusitis.
Most common organisms are S. aureus, S. pneumoniae, H. influenza, GABHS, and anaerobic organisms
Cataracts- Congenital: Rubella, Toxoplasmosis, Cytomegalovirus, genetic anomalies, prematurity and/or
drug exposure, hypocalcemia
Acquired: trauma (child abuse), systemic disease (diabetes, trisomy 21, hypoparathyroidism,
galactosemia, atopic dermatitis, hypocalcemia, Marfan syndrome, neurofibromatosis, toxins, drugs,
radiation, corticosteroid eye drops, glaucoma, uveitis, strabismus, pendular nystagmus.
Signs: decreased visual acuity, strabismus (initial sign), absent red reflex (leukocoria)
Treatment: Prompt referral to ophthalmologist, eyeglasses, surgery
Glaucoma- Congenital in first 3 years or juvenile between ages of 3 and 30 years
Secondary associated with trauma, intraocular hemorrhage/tumor, cataracts, corticosteroid use,
juvenile idiopathic arthritis, Marfan syndrome, neurofibromatosis, Rubella syndrome, Pierre Robin
syndrome.
Signs/symptoms: photophobia, abnormal overflow of tears and blepharospasm (eyelid spasm),
decreased vision (peripheral first) leading to tunnel vision, persistent extreme pain
Findings: corneal haziness, conjunctival injection, irregular corneal light reflex, enlargement optic cup,
increase intraocular pressure.
Treatment: Immediate referral to ophthalmologist, surgery first line. Postop steroids and cycloplegic
drops to prevent adhesions. No miotics.
Refractive errors- Impaired vision that can be improved with corrective lensesHyperopia (Farsightedness)
• Image focused behind retina
• Unable to see up close
• Headache, eye strain, squinting, eye rubbing, strabismus
• Passing vision screen is 20/40 (3-4 years) 20/30 (older children)
• Difference of two lines between the two eyes is significant
Myopia (Nearsightedness)
Image focused in front of retina
Appears around 8-10 years of age
Distant objects blurred
Children have trouble seeing blackboard
Astigmatism- Refractive error due to an irregular curvature of the cornea or changes in the lens causing
light rays to bend in different directions. Syndromes associated with juvenile idiopathic arthritis,
neurofibromatosis, congenital rubella syndrome
Amblyopia “lazy eye”- Most common cause of visual impairment in children.
Amblyopia = decreased/loss of vision in one eye. “Occurs when there is an interruption of the normal
visual stimuli in one eye…an actual physical change takes place in the neurons of the corresponding
visual cortex in occipital lobe.” Organic causes are related to trauma, organic lesion, cataract, diseases
of the eye or visual pathways, ptosis. Nonorganic causes are abnormal binocular interaction during
infancy and early childhood (greatest risk between 2-3 years of age but can continue until 9 years of
age); large difference in refractory errors between both eyes (anisometropia).
Cause: Most commonly secondary to refractive imbalance or strabismus.
Prevention: Correction of problem before visual maturity (6-7 years). The sooner the better. Patching of
good eye to stimulate weak innervated eye.
Cholesteatoma- Cystlike growth within the middle ear with lining of stratified squamous epithelium
filled with desquamated debris. Theory explaining formation due to inflammatory process, peforation,
or failure of desquamated tissue to clear from middle ear. Most common cause of acquired
cholesteatoma is chronic serous otitis media. If surgery is delayed, it can invade and destroy other
structures of the temporal bone and possibly spread to intracranial cavity, with life-threatening
consequences. If untreated, may lead to facial nerve paralysis, intracranial infection. Signs and
symptoms are dizziness and hearing loss. There is pearly white, opacity, on or behind tympanic
membrane. History of chronic OM with foul-smelling purulent otorrhea. Diagnostic test – CT scan of
the temporal bone and audiogram to rule out hearing deficit. Referral to ENT for surgical excision.
Pneumatic Otoscopy- Pneumatic Otoscopy
Using bulb attached to otoscope facilitates
assessment of movement of TM
Acute OM- little to no movement
otitis- Otitis Media: Organisms
Haemophilis influenza
Streptococcus pneumoniae
Moraxella catarrhalis
Others: group A streptococci, Staphlococcus aureus, pseudomonas aeruginosa, viruses
Note: Zithromax does not cover S. pneumo as well as Amoxicillin, and has low activity against M.
catarrhalis & lactamase producing H-influenza
Start with Amoxil at 80-90mg/kg/day ÷2 doses (for children over age 2 may
If severe illness or need coverage for B-lactamase positive organisms give Amoxil 90 mg/kg/day plus
Clavulanate 6.4 mg/kg/d ÷ 2 doses
If allergic to Penicillin but reaction not urticaria or anaphylaxis
Cefdinir (Omnicef) 14 mg/kg/d ÷ 1-2 doses
Cefpodoxime (Vantin) 10 mg/kg/d qd
Cefuroxime (Ceftin) 30 mg/kg/d ÷ 2 doses
If Type I sensitivity to Penicillin
Azithromycin (Zithromax) 10 mg/kg/d x 1 then 5mg/kg/d x 4 d
Reassess in 48-72 hours if don’t treat or if no better
Do discuss pain management with oral medication: Counsel parents on the specific dose, preparation,
and administration of Tylenol or ibuprofen •Do give ear drops for pain when appropriate
•Don’t use Auralgan or Americaine Drops for pain if child has a PE tube or a perforation! They are not
intended for contact with the middle ear
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Otitis Media: Classifications
OME (Otitis Media with Effusion): Painless middle ear effusion (MEE) without acute infection.
Most often follows AOM with mean duration of 40 days
AOM (Acute Otitis Media): middle ear effusion + acute pain + inflammation
Recurrent OM: Frequent OM with clearing in between
Chronic OME: persistence of fluid in middle ear for > 3 months
Bronchitis- Susanna is a three year old who presents to the clinic after having a mild upper
respiratory infection with a dry hacking cough that she seems to not be able to get rid of and
production of sputum. She says her chest burns and the coughing has made her vomit. She
does not have a fever. However, she does have rhonchi and coarse rales. There is no evidence
for cough suppressants or antihistamines. Bronchodilators are used with Susanna because she
does have wheezing as well. What test might be good to do and what two conditions should be
ruled out?
What age group has the highest airway resistance?
Newborns and young children
Genitourinary
UTI
enuresis
cryptorchidism
hypospadias
hematuria
proteinuria
testicular torsin
AGN
Hydronephrosis
Neck masses- CH 94 KiTTENS- (congenital/developmental, infectious/inflammatory, trauma, toxic,
endocrine, neoplasms, systemic disease) pg 678
Neck masses are usually due to infections or inflammation of lymph nodes, node location is clue to
underlying problem.
Dental trauma- maxillary incisors most common “injury”
Acsaris- round worm in digestive tract. Can move in to respiratory system causing wheezing and SHOB.