Evidence Based Pediatric
Treatment Guidelines 2014:
Clinical Practice Strategies for
the Retail Clinician
Wendy L. Wright, MS, RN, APRN, FNP, FAANP
Owner – Wright & Associates Family Healthcare
Partner – Partners in Healthcare Education
Facilitated by Partners In Healthcare and sponsored by Walgreens
Wright, 2014
1
Another Great Resource for
Pediatrics
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%201
01107.pdf accessed 05-01-2014
2
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Development &
Anticipatory Guidance
• Developmental Screening
– 9 months
– 18 months
– 30 months
• Identify those infants and children with
developmental disorders
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/3/645/F1
accessed 05-01-2014
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Development &
Anticipatory Guidance
• Anticipatory Guidance
–Every visit from birth – age 21
–Specific guidance is based upon
age
http://brightfutures.aap.org accessed 05-01-2014
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Eye Examinations and Vision
• AAP recommendations
– Begin vision screening as a newborn
– Formal screening at:
•
•
•
•
•
•
Age 3 years
Age 4 years
Age 5 years
Age 6 years
Age 8, 10, and 12 years
Age 15 and 18 years
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AAP Updates
• Hearing Screening
– Most common congenital developmental
abnormality affecting children in the United
States
– Screen before 1 month
– Repeat by 3 months if abnormal
– If abnormal, referred to early intervention
before age 6 months for formal evaluation
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http://aapnews.aappublications.org/content/32/8/36.2.extract accessed 05-01-2013
AAP Recommendations
• Universal newborn hearing screening
• Screenings for hearing impairment should be
performed periodically on all infants and
children in accordance with the following
schedule
– Newborn
– Age 4, 5, 6, and 8
– Risk assessments performed at all other wellchild visits
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/2/436 accessed
05-01-2014
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USPSTF Hearing Screening
Recommendations
• The USPSTF recommends screening for
hearing loss in all newborn infants
• All infants should have hearing screening before
1 month of age
• Those infants who do not pass the newborn
screening should undergo audiologic and
medical evaluation before 3 months of age for
confirmatory testing
– These children should undergo periodic monitoring
for 3 years
http://www.guidelines.gov/content.aspx?id=12640&search=hearing accessed 05-01-2014
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Dental Examination
• AAP recommendations
– Begin at age 12 months
– 18 months
– 24 months
– 30 months
– 3 years of age
– 6 years of age
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Autism Screening
• Universal screening
– Formal ASD screening on all children at 18
and 24 months regardless of whether there
are any concerns
– Guidelines stress that providers need to
ask/discuss any concerns that parents may
have at every well-child visit
http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011
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M-CHAT Screening Tool
• http://www.mchatscreen.com
• Conducted at 18 and 24 months
• Can learn to become certified autism
screener
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Look for the Presence
of Red Flags
• No babbling or pointing or other gesture by
12 months
• No single words by 16 months
• No two-word spontaneous phrases by 24
months
• Loss of language or social skills at any
age.
http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011
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Lead Screening
• AAP recommendations
– 12 months or…
– 24 months
• Continued risk factor assessment
throughout childhood
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sche
d%20101107.pdf accessed 05-01-2014
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Anemia Screening
• AAP recommendations
– Age 12 months
– Hemoglobin or hematocrit
• Continued risk assessment throughout
childhood
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%2
0Sched%20101107.pdf accessed 05-01-2014
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Children and Screening
• Begin at 10 years of age in children
at risk or at the onset of puberty, if
earlier than 10 years
–Repeat every 3 years, if normal
www.diabetes.org
www.aace.com
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What Constitutes a Risk Factor in
Children?
• Overweight (BMI>85th %tile for age and sex, weight for height >85th%tile, or
weight >120% of ideal for height)
• In addition – presence of two or more of the following:
– Family history of type 2 diabetes in first- or second-degree relative
– Race/ethnicity (Native American, African American, Latino, Asian
American, Pacific Islander)
– Signs of, or conditions associated with, insulin resistance including
acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary
syndrome, small for gestational age at birth history in the child
– Maternal history of DM or gestational DM
http://care.diabetesjournals.org/content/36/Supplement_1/S11.full accessed 05-20-2014
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General Health Counseling
•
•
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•
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•
Seatbelts
Helmets
Sunscreen
Smoke Detectors
Pool Safety
Carbon Monoxide
Guns
Domestic Violence
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General Health Counseling
• Drugs
• Alcohol
• Smoking
Remember –
School / sport physicals may be the only
contact that the child has with a health
care professional in a year
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Immunization schedule: aged 0 through 18 years—
United States, 2014
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ACIP Recommendations for Use
of Meningococcal Vaccine
• Routine vaccination of adolescents with MCV-4
– Individuals age 11 - 18
– Microbiologists who are routinely exposed to isolates
of Neisseria meningitidis
– Military recruits
– Persons who travel to, or reside in, countries in which
N meningitidis is hyperendemic or epidemic
– Complement-deficient and asplenic patients
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CDC. MMWR. 2005;54(RR-7):13.
ACIP Recommendations –
October 2010
• ACIP recommends routine vaccination of
adolescents with MCV4 beginning at age 11
through 12 years at the pre-adolescent vaccination
visit, with a booster dose at age 16 years.
• For adolescents vaccinated at age 13 through 15
years, a one-time booster dose should be given 3
to 5 years after the first dose.
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Updated ACIP
Recommendations
Why Change the Program Now?
• Data indicates protection wanes
within 5 years after vaccination
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HPV4
• Protects against 4 strains of HPV
– 16 and 18 – cause 70% of all cervical
cancer
– 6 and 11 – cause 90% of genital warts
– CDC just recommended administration
as young as 9 but ideally to 11 – 12 year
old girls
– Age limit: < 26 years of age
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HPV Vaccine
• Series of 3 injections
– Day 0, day - 2 months and day - 6 months
• .5 ml injection IM injection into deltoid
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Additional Indication for HPV4
• Indicated to reduce risk of genital warts in
males
• Also: reduction in anal cancers
• Ages: 9 years - < 26 years of age
• Universal recommendation for boys:
– 9 – 21 years
• Permissive recommendation for boys
– 22 – 26 years (insurance may not cover)
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Additional Approval
• HPV4
– Prevention of anal cancer and associated
precancerous lesions due to human
papillomavirus (HPV) types 6, 11, 16, and 18 in
people ages 9 through 26 years
– 78 percent effective in the prevention of HPV
16- and 18-related AIN
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Influenza
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Important Influenza Messages
• Begin to vaccinate as soon as flu vaccines are
received in clinics
• Immunity lasts throughout entire flu season,
even if vaccines are given in August
• All healthcare professionals who care for
patients in a protected environment (severely
immunocompromised) should receive the
Trivalent Inactivated Vaccine (TIV) rather than
LAIV
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Egg Allergy and TIV
• 2011 - The recommendation is as follows:
– For patients with a history of egg allergy WITHOUT
anaphylaxis, there is no need to divide doses or perform skin
testing before vaccination
– There will be no need to confirm the levels of ovalbumin in
the 2011-12 flu vaccine because all products will contain
less than 0.6 micrograms per dose;
– Patients with egg allergy should be observed for 30 minutes
after vaccination; and
– Vaccine providers should be equipped and trained to handle
anaphylactic emergencies
– Do not use LAIV (Flumist)
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New Information
• 2014-2015 strains for influenza vaccine
announced
• Trivalent or Quadrivalent
– A/California/7/2009 (H1N1)
– A/Victoria/361/2011 (H3N2)
– B/Massachusetts/2/2012
– Quad: B/Brisbane/60/2008
•
http://www.who.int/influenza/vaccines/virus/en/ accessed 05-01-2014
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MMR and Travel
• Before departure, children aged 6–11
months should receive the first dose of
MMR vaccine
– Infants vaccinated before age 12 months must
be revaccinated on or after their first birthday
with 2 doses of MMR vaccine, separated by at
least 28 days
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infantsWright, 2014
children/vaccine-recommendations-for-infants-and-children.html
accessed 12-30-201231
Management of Fever
• Definition
– Temperature > 37.2° C orally or > 98.9° F in
am
– OR….> 37.7° C orally or > 99.9° F in
afternoon – pm
• When child presents with a fever of 5 – 7
days or less, must consider:
– Viral vs. Bacterial infections
– Bacteremia
– Sepsis
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Worrisome Findings:
Consider Hospitalization
•
•
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•
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•
•
•
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Altered LOC
Abnormal breathing
Tachycardia in presence of significant findings
Significantly elevated temperature
Petechiae
Cyanosis
Pallor
Delayed capillary refill (> 2 seconds)
Poor muscle tone
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Management of Fever
• Antipyretics
– May mask signs and symptoms of serious
conditions
– Side effects may occur from these medications
– Do not alter course of illness
• Benefits
– Good when fever is > 103
– Always recommend in children with history of
febrile seizure
– May make more comfortable
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Management of Fever
• Options for treatment (weight/age dosing)
– Acetaminophen
– Ibuprofen
• Caution regarding cool sponge baths
• Education:
– Monitor closely
– Reinforce when to call or return
– Avoid aspirin and related products
– Increase fluids
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Clinical Pearl:
Document visual
acuity on all eye
complaints
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Hordeolum
• Etiology
– Obstruction of the glands of Zeiss
– Staphylococcal aureus is the most common
causative organism
• History
– Swollen, red, painful lesion on the lid margin
– Itchiness of the eyelid
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Hordeolum
• Physical examination
– Erythematous, tender nodule on the margin of the
eyelid
– Surrounding edema
• Treatment
– Warm compresses-20 minutes qid
– Antimicrobial ointment or drops
– Good eye hygiene and handwashing
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Hordeolum
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Internal Hordeola
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Viral Conjunctivitis
• Etiology
– Adenovirus is the most common cause
• 40 strains identified
– Recent studies have shown that it can remain
viable on plastic and metal surfaces for up to 1
month
• Symptoms
– Watery discharge, foreign body sensation, redness
– URI symptoms are common including sore throat
and fever
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– Often bilateral
Viral Conjunctivitis
• Signs
– Normal visual acuity, PERRLA, EOMI, Fund nl
– Mucoid-slightly watery discharge
– Mild, diffuse injection
– Preauricular lymphadenopathy
• Treatment
– Symptomatic only
– Cool compresses
– Strict eye hygiene
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Viral Conjunctivitis
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Bacterial Conjunctivitis
• Etiology
– Staphylococcus aureus
– Streptococcus pneumoniae/pyogenes
– Haemophilus influenzae
– Neisseria gonorrhea
• Symptoms
– Redness, swelling, purulent discharge, itching
– No symptoms until eye complaints began
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Bacterial Conjunctivitis
• Signs
– Normal visual acuity, PERRLA, EOMI, Fund nl
– Diffuse injection
– No ciliary injection
– Unilateral at onset
• Treatment
– Topical antimicrobials x 5-7 days
– Warm compresses qid x 10-20 minutes
– Strict eye hygiene given contagion
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Bacterial Conjunctivitis
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Conjunctivitis
• Viral
– Palpable preauricular
node
– Watery discharge
– Mild-moderate
conjuctival injection
– URI symptoms
– Bilateral
• Bacterial
– Non-palpable nodes
• GC and Chlamydia +
– Purulent discharge
• GC-Mucopurulent
– Moderate
conjunctival
injection
– Unilateral at onset
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Allergic Conjunctivitis
• Two types of allergic conjunctivitis
– Seasonal and perennial
• Seasonal is most common and caused by
the following triggers
– Pollens
– Grass
– Ragweed
• Perennial persists all year and is caused by
indoor allergens, such as dust mites
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Signs and Symptoms
• Symptoms
– Itching
– Watery– stringy-like clear discharge
• Signs
– Injected conjunctiva
– Other physical examination findings such as:
•
•
•
•
Dennie’s lines
Allergic shiners
Allergic facies
Allergic crease
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Treatment
• Systemic and/or topical antihistamines relieve
acute symptoms due to interaction of histamine at
ocular H1 and H2 receptors
• Examples of topical antihistamines include:
epinastine (Elestat) and azelastine (Optivar)
• Vasoconstrictors are available either alone or in
conjunction with antihistamines to provide shortterm relief of vascular injection and redness
• Common vasoconstrictors include naphazoline,
phenylephrine, oxymetazoline, and tetrahydrozoline
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Treatment
• Mast cell stabilizers include cromolyn
sodium and lodoxamide (Alomide),
Olopatadine (Patanol), nedocromil (Alocril)
• Nonsteroidal anti-inflammatory drugs
(NSAIDs) act on the cyclooxygenase
metabolic pathway and inhibit production of
prostaglandins. One example is: ketorolac
tromethamine (Acular)
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IDSA Clinical Practice Guideline
for Acute Bacterial Rhinosinusitis
in Children and Adults
Clinical Infectious Diseases Advance
Access published March 20, 2012
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
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Algorithm for the management of acute bacterial
rhinosinusitis
Chow A W et al. Clin Infect Dis. 2012;cid.cir1043
© The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases
Society of America. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com.
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What Constitutes at Risk for
Resistance?
•
•
•
•
•
•
Age < 2 years or > 65 years
Daycare
Antimicrobial within past 1 month
Hospitalization within past 5 days
Comorbidities
Immunocompromised
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
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Goals of Treatment
• Restore integrity and function of
ostiomeatal complex
– Reduce inflammation
– Restore drainage
– Eradicate bacterial infection
http://www.medscape.com/viewprogram/5621 accessed 01-22-07
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Treatment of Acute
Bacterial Rhinosinusitis
• Nonpharmacologic Therapies
– Cold steam vaporizer
– Increased water intake
– Intranasal saline irrigations with either physiologic
or hypertonic saline are recommended as an
adjunctive treatment in adults with ABRS1
1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
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Management Strategies in ABRS
• Antihistamines or decongestants
– No longer recommended
• Topical corticosteroids
– Intranasal corticosteroids are recommended as an adjunct to
antibiotics in the empiric treatment of ABRS, primarily in
patients with a history of allergic rhinitis1
• Corticosteroids
1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
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Antimicrobial Regimens in Children
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
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accessed
12-29-2012
Important Changes
• Macrolides (clarithromycin and azithromycin) are not
recommended due to high rates of resistance among
S. pneumoniae (30%)
• TMP/SMX is not recommended due to high rates of
resistance among both S. pneumoniae and H.
influenzae (30%–40%)
• Second and third-generation cephalosporins are no
longer recommended due to variable rates of
resistance among S. pneumoniae.
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
accessed
12-29-2012
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Length of treatment
• The recommended duration of therapy for
uncomplicated ABRS in adults is 5–7 days
• In children with ABRS, the longer
treatment duration of 10–14 days is still
recommended
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
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When to Change Treatments
• An alternative treatment should be
considered if symptoms worsen after 48–
72 hours of initial empiric antimicrobial
therapy, or when the individual fails to
improve despite 3–5 days of antimicrobial
therapy
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
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When to Refer
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
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Accessed
Ear Conditions
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Variations of Tympanic
Membrane
Normal TM
Acute OM
Otitis Media
with Effusion
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AAP Updated Guidelines
• Diagnosis of AOM:
– Evidence: 1A
• Moderate - severe bulging of TM
• OR…new otorrhea NOT due to otitis externa
– Evidence: 1B
• Mild bulging of TM and….
• Recent ( < 48 hours) onset of ear pain or….
• Intense erythema of TM
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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AAP Updated Guidelines (cont.)
• Severe AOM:
– Prescribe antimicrobial for AOM in children 6
months or older with severe signs and symptoms
• Moderate or severe otalgia for at least 48 hours OR…
• Temperature: 102.2 (39 degrees Celsius)
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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AAP Updated Guidelines (cont.)
• Nonsevere bilateral AOM in children < 24
months without signs or symptoms:
– Antibiotics should be prescribed even in the
setting of mild symptoms
• Mild otalgia < 48 hours
• Temperature < 39 degrees Celsius
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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AAP Updated Guidelines (cont.)
• Nonsevere unilateral AOM in children age 6
month – 23 months:
– Two options:
• Antimicrobial therapy
• Observation as treatment option
– Nonsevere
– Follow-up must be ensured
– Start antimicrobials if worsen or no improvement with 48 – 72
hours
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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AAP Updated Guidelines (cont.)
• Nonsevere AOM in older children (24 months
or older):
– Two options:
• Antimicrobial therapy
• Observation as treatment option
– Nonsevere
– Follow-up must be ensured
– Start antimicrobials if worsen or no improvement with 48 – 72
hours
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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Summary: AAP Updated
Guidelines (cont.)
AGE
Otorrhea with
AOM
Unilateral or
Bilateral AOM
with Severe
Symptoms
Bilateral AOM
without
Otorrhea
Unilateral
AOM without
Otorrhea
6 months – 2 years
Antibiotic
Antibiotic
Antibiotic
Antibiotic
therapy or
observation
> 2 years
Antibiotic
Antibiotic
Antibiotic or
observation
Antibiotic or
observation
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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AAP Updated Guidelines (cont.)
• Treatment options:
– Amoxicillin: first line
• Provided that: no antibiotics in previous 30 days and
• No purulent conjunctivitis and
• Not allergic to PCN
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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AAP Updated Guidelines (cont.)
• Treatment options:
– Amoxicillin/clavulanate
• Child who has received antibiotics in previous 30 days
OR….
• Has concurrent purulent conjunctivitis OR….
• History of AOM which is unresponsive to amoxicillin
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
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Initial Immediate or Delayed
Antibiotic Treatment
Recommended First line Treatment
Alternative Treatment
(if Penicillin Allergy)
Amoxicillin (80-90 mg/kg/day) in two
divided doses OR
Cefdinir (14 mg/kg/day) in one – two divided
doses
Cefuroxime (30 mg/kg/day) in two divided
doses
Amoxicillin/clavulanate (90 mg/kg/day or
amoxicillin) with 6.4 mg/kg/day of
clavulanate) in two divided doses
Cefpodoxime (10mg/kg/day) in two divided
doses
Ceftriaxone (50 mg IM or IV) daily for 1 or 3
days
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy76
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ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
Antibiotic Treatment After 48-72
hours of Failure of Initial Antibiotic
Recommended First line Treatment
Alternative Treatment
(if Penicillin Allergy)
Amoxicillin/clavulanate (90 mg/kg/day or
amoxicillin) with 6.4 mg/kg/day of
clavulanate) in two divided doses
Ceftriaxone 3 day
Clindamycin (30 – 40 mg/kg/day) in three
divided doses with or without concomitant
third generation cephalosporin
Clindamycin (30 – 40 mg/kg/day) in three
divided doses with concomitant third
generation cephalosporin
Tympanocentesis
Consult specialist
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy77
Wright, 2014
ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
Ceftriaxone (50 mg IM or IV) for 3 days
Remember…
• For children with OM and tympanostomy
tubes:
– You may also utilize topical medications
– Ofloxacin (Floxin Otic) 0.3% solution
• Age 1 - 12 years: 5 drops into affected ear bid x 10
days
– Ciprofloxacin (Ciprodex):
• 6 months and up: 4 drops into the affected ear bid x 7
days
Wright, 2014
78
Duration of Treatment for AOM
• Results
– 10 days: Patients <2 years old or those with
severe symptoms
– 7 days: Age 2-5 years of age with mild – moderate
AOM
– 5 – 7 days: 6 years and older with mild – moderate
symptoms
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&
gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psyab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556
accessed 05-01-2013
Wright, 2014
79
Otitis Media with Effusion
• Fluid in the middle ear
• No signs and symptoms of AOM
– Air fluid levels
– Dullness of TM
– Decreased movement of TM
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010
Wright, 2014
80
OME
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81
OME
• Treatment:
– Observation as a treatment option
– Majority – up to 90% will resolve within 3 months
without intervention
– If still present at 12 weeks – may need hearing
evaluation, referral to ENT
– High risk individuals may be candidates for
myringotomy
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010
Wright, 2014
82
Otitis Externa
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83
Otitis Externa
• Pathophysiology
– Inflammation +/or infection of the external
auditory canal
– Associated with prolonged water
exposure, inserting objects into ear,
scratching the ear
– 10-20x more common in the summer
– Children with eczema, psoriasis,
seborrhea are at a greater risk
– Most common cause: Pseudomonas
Wright, 2014
84
Otitis Externa
• Symptoms
– Unilateral ear pain
– Discharge from the ear
– Low grade fever
– Recent history of swimming or placing
something in ear
– Pain with tragal movement
– Redness around ear
– Decreased hearing
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85
Otitis Externa
• Signs
–Erythematous, edematous canal
–Pain with tragal/pinna movement
–Yellow/green discharge
–Foreign body
–Pre or postauricular lymphadenopathy
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86
Otitis Externa
• Plan
– Diagnostic
• None
• Can check culture
– Therapeutic
• Remove foreign body
• Irrigate canal
• Erythromycin (Cortisporin) Otic Ear Solution: 4 drops qid
into affected ear x 5 days
• Ciprofloxacin (Ciprodex) 3 – 4 drops tid into affected ear x
7 days
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87
Otitis Externa
• Plan
– Therapeutic
• Warm compresses
• NSAIDS/Tylenol
• Prednisone
• Auralgam
• Wick
Wright, 2014
88
Otitis Externa
• Plan
– Educational
• Avoid prolonged water exposure - ear plugs
• Ear wax removal kits
• Prevention: Oil into canal; Vaseline on cotton
ball
• No Q tips in ear
• Try to remove all water after bathing by
manipulating ear
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89
Pharyngitis
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90
Pharyngitis
• Epidemiology
–Group A Beta Hemolytic Strep
• Most interest because of its
association with severe complications
• Peritonsillar abscesses, rheumatic
fever, post-streptococcal
glomerulonephritis - complications
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91
Pharyngitis
• Symptoms
– Group A Beta Hemolytic Strep
•
•
•
•
•
•
•
•
•
Rapid onset of sore throat
Fever 103-104
Swollen glands
Children often complain of abdominal pain
Usually-no URI symptoms
Headache
Decreased appetite
Dysphagia
Irritability
Wright, 2014
92
Exudative pharyngitis
Exudative pharyngitis
Differentials include:
Strep pharyngitis
Peritonsillar abscess
Mononucleosis
Viral pharyngitis
Wright, 2014
93
Pharyngitis
• Plan
–Diagnostic
• Throat culture: 24 hour is the gold
standard
• Quick strep: 85-100% sensitivity; 31-95%
specificity
• Must swab both tonsils for best results
• Consider mononucleosis
Wright, 2014
94
Pharyngitis
Even with a best case scenario, 1/3 1/2 of cases of strep pharyngitis are
missed or overdiagnosed using
history and physical examination
only!!!
MUST DO A THROAT CULTURE
Wright, 2014
95
Remember…
Children with mono
have strep
pharyngitis 50% of
the time
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96
Pharyngitis
• Plan
– Therapeutic: Strep Pharyngitis
•
•
•
•
PCN VK-standard
Treatment is for 10 days
Warm water gargles
Tylenol/NSAID’s
– Educational
• Contagion
• Quick improvement
• Discard toothbrush
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97
Peritonsillar Abscess
• Generally begins as an acute febrile URI or
pharyngitis
• Condition suddenly worsens
– Increased fever
– Anorexia
– Drooling
– Dyspnea
– Trismus
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Peritonsillar Abscess
• Physical examination
– May appear restless
– Irritable
– May lie with head hyperextended to facilitate
respirations
– Muffled voice
– Stridor may be present
– Respiratory distress
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Peritonsillar Abscess
• Physical examination findings
–Fiery red asymmetric swelling of
one tonsil
–Uvula is often displaced
contralaterally and often forward
–Large, tender lymphadenopathy
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Peritonsillar Abscess
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101
Peritonsillar Abscess
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102
Important Reminder
•If respiratory
distress is severe,
do not examine
the pharynx
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103
Treatment
• Aspiration of the abscess may be
performed for accurate diagnosis and
treatment
• CT scan of the head and neck
– Monitor airway at all times
• ENT consult is essential
• Usual management
– IV antibiotics
– Inpatient management
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Viral Upper
Respiratory Infection
• Caused by the rhinovirus, adenovirus or
coronavirus
• Transmitted through respiratory droplets
• Most common ages: 4 – 7 years
• Begins with sore throat, low grade fever
and progresses on to include nasal
congestion and a cough
• Typically lasts 3 – 14 days
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105
Treatment
• Mainly symptomatic
– Avoid cough and cold medications in
individuals < 2 years of age
• Consider the following:
– Decongestants
– First generation antihistamines
– Cough suppressants
– Guaifenesin products
– Chicken soup Wright, 2014
106
General Signs and Symptoms
of Respiratory Distress
• Respiratory rate which is > 50% above
upper limits of normal for age
• Intercostal retractions
• Nasal flaring
• Substernal retractions
• Grunting with breathing
• Cyanosis/pallor
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Asthma and
Asthma
Exacerbation
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108
Impact of Asthma
• Most frequent cause for hospitalization in children
(470,000 each year)
– Emergency room visits and hospitalizations are
increasing
• Most frequent cause of childhood death,
particularly amongst certain groups (children,
african americans)
– 5,000 people die yearly from asthma
Wright, 2014
109
Asthma is...
• A disease of:
– Inflammation
• Primary Process
– Hyperresponsiveness
– Airway bronchoconstriction
– Excessive mucous production
Wright, 2014
110
Epithelial Damage in Asthma
Normal
Wright, 2014
Jeffery P. In: Asthma, Academic Press 1998.
Asthmatic
111
Diagnosis of Asthma
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112
What is Asthma
• “A common chronic disorder of the airways
that is complex and characterized by
variable and recurring symptoms, airflow
obstruction, bronchial
hyperresponsiveness, and underlying
inflammation.”
National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis
and Management of Asthma, Full Report 2007.
Wright, 2014
113
Diagnosis of Asthma
• History and Physical Examination
• Pulmonary Function Tests
• Monitoring:
– Peak Flow Meters
Wright, 2014
114
Symptoms and Signs
of Asthma in Children
•
•
•
•
•
Coughing, particularly at night
Wheezing
Chest tightness
SOB
Cold that lingers x months with a
persistent cough
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115
Diagnosis
• Consider the diagnosis of asthma and
perform spirometry if any of these
indicators are present. These indicators
are not diagnostic by themselves but the
presence of multiple key indicators
increases the probability of the diagnosis
of asthma. Spirometry is needed to make
the diagnosis of asthma.
National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis
and Management of Asthma, Full Report 2007.
Wright, 2014
116
Figure 17-1 Classifying Asthma Severity and Initiating
Treatment in Children 0 to 4 Years of Age
Persistent
Intermittent
Mild
Moderate
Severe
≤2 days/week
>2 days/week
but not daily
Daily
Throughout
the day
Nighttime awakenings
0
1-2x/month
3-4x/month
>1x/week
SABA use for symptom
control (not prevention
of EIB)
≤2 days/week
>2 days/week
but not daily
Daily
Several times
per day
Interference with
normal activity
None
Minor limitation
Some limitation
Extremely limited
Components of Severity
Impairment
Symptoms
Exacerbations requiring
oral systemic corticosteroids
0-1/year
≥2 exacerbations in 6 mos requiring oral systemic corticosteroids, or ≥4
wheezing episodes/1 year lasting >1 day & risk factors for persistent asthma
Risk
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time
Exacerbations of any severity may occur in patients in any severity category
Step 1
Recommended Step
for Initiating Treatment
Step 2
Step 3 and consider short course of oral
systemic corticosteroids
In 2 to 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit
is observed in 4 to 6 weeks, consider adjusting therapy or alternative diagnoses
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Stepwise Approach for Managing Asthma in Children
Age 0 to 4 Years
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if Step 3 care or higher is required.
Consider consultation at Step 2.
Step 6
Step 2
Step 1
Preferred:
SABA
PRN
Preferred:
Low-dose
ICS
Alternative:
Cromolyn
or
Montelukast
Step 3
Preferred:
Step 4
Preferred:
Medium-dose
Medium-dose ICS + either
ICS
LABA
or
Montelukast
Step Up if
Step 5
Preferred:
Needed
(first check
High-dose
Preferred:
adherence,
ICS + either
High-dose ICS
inhaler
LABA or
+ either LABA Montelukast
technique, &
or
environmental
and
Montelukast Oral Systemic
control)
Corticosteroids
Assess
Control
Patient Education and Environmental Control at Each Step
Quick-Relief Medication for All Patients
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms
• With viral respiratory infection: SABA q 4-6 hours up to 24 hours (longer with physician consult).
• Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of
previous severe exacerbations
• Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations
on initiating daily long-term-control therapy
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Step Down if
Possible
(& asthma is
well controlled
at least 3
months)
Classifying Asthma Severity and Initiating Treatment in Children 5
to 11 Years of Age
Persistent
Impairment
Components of Severity
Mild
Moderate
Severe
Symptoms
≤2 days/week
>2 days/week
but not daily
Daily
Throughout
the day
Nighttime awakenings
2x/month
3-4x/month
>1x/week but
not nightly
Often 7x/week
SABA use for symptom
control(not prevention of
EIB)
≤2 days/week
>2 days/week
but not daily
Daily
Several times
per day
None
Minor limitation
Some limitation
Extremely limited
• FEV1 80%
predicted
• FEV1/FVC >80%
• FEV1=60%-80%
predicted
• FEV1/FVC=
75%-80%
Interference with
normal activity
Lung Function
Risk
Intermittent
Exacerbations
requiring oral
systemic
corticosteroids
Recommended Step
for Initiating Treatment
• Normal FEV1
between
exacerbations
• FEV1 >80%
predicted
• FEV1/FVC>85%
0-1/year
• FEV1<60%
predicted
• FEV1/FVC
<75%
≥2/year
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV1
Step 1
Step 2
Step 3, medium-dose
ICS option
Step 3, med.-dose
ICS option, or
Step 4
& consider short course of oral systemic
corticosteroids
In 2 to 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly
Stepwise Approach for Managing Asthma
in Children Age 5 to 11 Years
Persistent Asthma: Daily Medication
Intermittent
Asthma
Step 1
Preferred:
SABA PRN
Consult w/ asthma specialist if Step 4 care or higher is required.
Consider consultation at Step 3.
Step 2
Preferred:
Low-dose
ICS
Alternative:
Cromolyn,
LTRA,
Nedocromil,
or
Theophylline
Step 3
Preferred:
Low-dose ICS +
either LABA
LTRA or
Theophylline
OR
Medium-dose
ICS
Step 4
Preferred:
Medium-dose
ICS + LABA
Alternative:
Medium-dose
ICS + either
LTRA
or
Theophylline
Step 5
Preferred:
High-dose ICS +
LABA
Alternative:
High-dose ICS +
either LTRA
or
Theophylline
Step 6
Preferred:
High-dose ICS +
LABA +
Oral Systemic
Corticosteroid
Alternative:
High-dose ICS +
either LTRA or
Theophylline
+
Oral Systemic
Corticosteroid
Each Step: Patient education, environmental control, and management of comorbidities
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
Quick-Relief Medication for All Patients
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: Up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed
• Caution: Increasing of use of SABA or use>2 days a week for symptom relief (not prevention of EIB) indicates inadequate control
and the need to step up treatment
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Step Up if Needed
(first, check
adherence, inhaler
technique,
environmental
control, and
comorbid
conditionals)
Assess
Control
Step Down if
Possible
(and asthma is
well-controlled at
least 3 months)
Stepwise Approach for Managing Asthma in
Patients Aged≥12 Years
Intermittent
Asthma
Step 1
Persistent Asthma: Daily Medication
Consult with asthma specialist if Step 4 care or higher is required.
Consider consultation at Step 3.
Step 6
Step 5
Step 4
Preferred:
Step 3
High-dose ICS
Preferred:
Preferred:
Preferred:
High-dose ICS + + LABA + Oral
Medium-dose
Step 2
Low-dose ICS +
Corticosteroid
LABA (B)
ICS + LABA (B)
Preferred:
LABA (A)
Low-dose ICS (A)
OR
Medium-dose
ICS (A)
Alternative:
Medium-dose
ICS +
either
LTRA (B),
Theophylline (B),
or Zileuton (D)
AND
AND
Step Up if
Needed
(first, check
adherence,
environmental
control, and
comorbid
conditions)
Consider
Assess
Omalizumab
SABA PRN
Cromolyn (A),
Control
for Patients
Alternative:
LTRA (A),
Low-dose ICS +
Who
Nedocromil (A),
Step Down if
either
LTRA
(A),
or
Have
Theophylline (B),
Possible
Theophylline (B)
Allergies
or Zileuton (D)
(and asthma
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
is well
Quick-relief medication for all patients
controlled at
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up
least 3
to 3 treatments at 20-minute intervals as needed. Short course of systemic oral
months)
corticosteroids may be needed
• Use of SABA >2 days a week for symptom relief (not prevention
of EIB) generally indicates
121
Wright, 2014
inadequate control and the need to step up treatment
www.nhlbi.nih.gov/guidelines/asthma/asthgdln
Preferred:
Alternative:
Consider
Omalizumab
for Patients
Who Have
Allergies (B)
Major Focus in EPR-3
• Controlling asthma is a
major focus of the EPR-3
guidelines
Wright, 2014
122
Assessing Asthma Control
(Youths 12 Years of Age and Adults)
Follow-up Visits: Determine Level of Control and Treatment Needed
Components of Control
Symptoms
Impairment
Wright, 2014
≤2 days/week
Not Wellcontrolled
Very Poorly
Controlled
>2 days/week
Throughout the day
Nighttime awakenings ≤2 x/month
1-3x/week
≥4x/week
Interference with
normal activity
None
Some limitation
Extremely limited
Short-acting beta2agonist use for
symptom control (not
prevention of EIB)
≤2 days/week
>2 days/week
Several times per day
FEV1 or peak flow
>80%
predicted/personal
best
60-80%
predicted/personal
best
<60% predicted/personal
best
0
≤0.75*
≥20
1-2
≥1.5
16-19
3-4
N/A
≤15
Validated
Questionnaires
ATAQ
ACQ
ACT
Risk
Well-controlled
Exacerbations
0-1/year
≥2/year (see note)
Consider severity and interval since last exacerbation
Progressive loss of
lung function
Evaluation requires long-term follow-up care
Treatment-related
adverse effects
Medication side effects can vary in intensity from none to very troublesome
and worrisome. The level of intensity does not correlate to specific levels of
123
control but should be considered in the overall assessment of risk.
*ACQ values of 0.76-1.4 are indeterminate regarding well-controlled asthma.
Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second. See figure 3-8 for full name and source of ATAQ, ACQ, ACT.
Monitoring Control in Clinical Practice:
Asthma Control Test™ for Patients Aged ≥12 Years1
Level of
Control Based
on Composite
Score2
≥20 =
Controlled
16-19 =
Not Well
Controlled
≤15 =
Very Poorly
Controlled
Regardless of
patient’s self
assessment of
control in
Question 5
1. Asthma Control Test™ copyright, QualityMetric Incorporated 2002, 2004. All rights reserved.
124
Wright,
2014
2. Available
at: http://www.nhlbi.nih.gov/guidelines/asthma/epr3/resource.pdf.
Accessed February 5, 2007.
Acute Asthma
Exacerbation
Management
Wright, 2014
125
Case Study
• 6 year old who presents with a 2 day history
of increasing sob and wheezing
• Began after developing a URI
• + nasal discharge, wheezing, cough, fever –
99.6
– Denies ST, ear pain, sinus pain, pain with
inspiration
• Meds: none
• Allergies: NKDA
• PMH: Bronchiolitis: age 6 months –
required hospitalization
Wright, 2014
126
Physical Examination
• 6 year old who is wheezing audibly and
obviously uncomfortable
– RR: 30 and labored
– Pulse: 124 bpm
– Lungs: + inspiratory and expiratory wheezes
– No use of accessory muscles
– Remainder of exam is unremarkable
Wright, 2014
127
Acute Asthma Exacerbation
• Measure Spirometry vs. Peak Flow
• FEV1 is most important number
– >80% predicted
– 50% – 79% of predicted
– < 50% of predicted
Wright, 2014
128
Spirometry Results
• FEV1 = 62% of predicted
• FEV1/FVC = 90%
• What does this mean for our
patient?
Wright, 2014
129
Acute Asthma Exacerbation
• Inhaled short acting beta 2 agonist:
– Up to three treatments of 2-4 puffs by
MDI at 20 minute intervals OR a single
nebulizer
• Can repeat x 1 – 2 provided patient
tolerates
– Albuterol or similar via nebulizer
– Reassess spirometry or peak flow after
Wright, 2014
130
Prednisone
• Multiple products available
• Prelone, Orapred, Prednisone
– 1 mg/kg daily (may split dosage)
• Example: Prednisone 10 mg bid x 3 - 10
days
• No taper necessary
Wright, 2014
131
Home Nebulizer
• May be important to order the patient
a nebulizer to be delivered to his/her
home
• Will be set up by a respiratory
company
• Patient and parent will be taught
appropriate utilization
Wright, 2014
132
Patient Education
•
•
•
•
Have plan in place for next URI
Preventative therapy?
Environmental modification
Daily peak flows
Wright, 2014
133
Severity of Acute Exacerbations
Wright, 2014
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
accessed 05-01-2014134
Bronchiolitis
Wright, 2014
135
Bronchiolitis
• Bronchiolitis is the most common lower
respiratory tract infection in infants and is
usually caused by a viral infection
• Most common cause: respiratory syncytial
virus
• RSV is responsible for > 50% of all cases
• Other causes: adenovirus and influenza
• Most commonly seen in the winter and
spring
Wright, 2014
136
Bronchiolitis
• Bronchiolitis
–Affects infants and young children most
often because their small airways
become blocked by mucous more easily
than older children
–Usually occurs between birth and 2
years of age
–Peak occurrence: 3 – 6 months
Wright, 2014
137
Burden of Illness
• Typically, bronchiolitis is a mild illness
• Risk factors for more severe illness
include:
– Prematurity
– Heart or lung disease
– Weakened immune system
Wright, 2014
138
Complications of Bronchiolitis
• Hospitalization
• Respiratory distress
• Children with this condition are
more likely to develop asthma
later in life
Wright, 2014
139
Signs and Symptoms
• Usually presents as the common cold
initially
– Nasal congestion
– Runny nose
– Cough
• These symptoms typically last for 1 -2
days and then symptoms begin to worsen
– Fever
– Vomiting after coughing
Wright, 2014
140
Signs and Symptoms
• Cough worsens
• Wheezes frequently occur
– High pitched sounds indicating a difficulty with
air movement
• Worsening respiratory distress may occur
– Retractions
– Flaring of the nostrils
– Irritability
– Tachycardia and tachypnea
Wright, 2014
141
Incubation Period and Duration
• Incubation period is:
– Days – 1 week
– This is dependent upon which virus is
responsible for the infection
• Duration of symptoms
– Typically 7 days but children with severe
cases may cough for weeks
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142
Treatment
• Symptomatic treatment is the most
common treatment
– Increased fluids
– Cool mist vaporizer to thin the
secretions
– Tilting the child’s mattress up may be
beneficial
• Antibiotics are not helpful
Wright, 2014
143
Pharmacotherapy
• Corticosteroids
• Inhaled corticosterioids
Wright, 2014
144
Bronchitis
Wright, 2014
145
Bronchitis
• Definition: Inflammatory condition
of the tracheobronchial tree
–Acute bronchitis
• Most cases of acute bronchitis are viral
(90-95%)
• 5% are bacterial
–Most frequent cause of bacterial
bronchitis – atypical pathogen (i.e.
mycoplasma) Wright, 2014
146
Treatment for Bronchitis
•
•
•
•
•
•
Symptomatic
Increase fluids
Steam
Guiafenesin or similar
First generation antihistamine
Cough syrup – usually not helpful or
effective
Wright, 2014
147
Bronchitis
• Treatment
–Antibiotics rarely needed
• If needed, atypical pathogen coverage
–Prednisone
• Short, non-tapering burst is often very
effective
• i.e. 5 days
Wright, 2014
148
Pertussis
Wright, 2014
149
Pertussis:
Preventable but Persistent
“There is a relative lack of awareness among health-care
providers that pertussis immunity from natural infection or
childhood vaccination wanes 5-8 years after the last
booster dose. This leaves adolescents and adults
vulnerable to pertussis infection, and those infected can
transmit risk of life-threatening disease to young infants.”1
Reference: 1. Healy CM, et al. Vaccine. 2009;27(41):5599-5602.
150
Eye of Science /Photo Researchers, Inc.
Pertussis: Highly Communicable,
Frequently Overlooked
• Acute respiratory tract infection caused
by Bordetella pertussis (gram-negative
aerobic bacillus)1
• Highly communicable (90%-100%
secondary attack rate among susceptibles)2,3
• Morbidity in all ages, especially infants1,2
• The cause of 13%-17% of cases of prolonged cough in
adolescents and adults4
• Adolescents, adults with unrecognized or untreated
pertussis contribute to the reservoir of B pertussis in the
community and pose a risk of transmission to others1
References: 1. Centers for Disease Control and Prevention (CDC). MMWR. 2005;55(RR-14):1-16. 2. CDC. MMWR.
2006;55(RR-17):1-37. 3. Long SS: Pertussis (Bordetella pertussis and Bordetella parapartussis.) In: Kliegman RM, Behrman
Wright,
2014Philadelphia, PA: Saunders Elsevier;2007:1178RE, Jenson HB, Stanton BF, eds, Nelson Textbook of Pediatrics.
18th edition.
1182. 4. Cherry JD. Pediatrics. 2005;115(5):1422-1427.
151
Reported Cases of Pertussis Are Highest
in Adolescents and Adults …
• ~10,000-25,000 cases of pertussis
are reported in the US every year1
• ~60% of reported cases occur
among adolescents and adults2
• Reported cases are the tip of
the iceberg
– Estimated actual cases among
adolescents and adults:
800,000-3.3 million per year3
Courtesy of the Centers for Disease Control
and Prevention (CDC).
“Despite increasing awareness and recognition of pertussis as a disease
that affects adolescents and adults, pertussis is overlooked in the
differential diagnosis of cough illness in this population.”4
References: 1. CDC. (Published July 9, 2009 for 2007). MMWR. 2007;56(53):1-94. 2. CDC. Data on file (Pertussis
Surveillance Reports), 2003-2008. MKT 17595 (2003-2006);
(2007); MKT 18761 (2008). 3. Cherry 152
JD.
Wright,MKT18596
2014
Pediatrics. 2005;115(5):1422-1427. 4. CDC. MMWR. 2005;55(RR-14):1-16.
The Very Young are Very Vulnerable to
Complications of Pertussis
Pertussis complications, hospitalizations, and deaths1
Age
No. with
pertussisa Hospitalization
Pneumonia Seizures Encephalopathy Death
<6 months
7203
4543
847
103
15
56
6-11 months
1073
301
92
7
1
1
1-4 years
3137
324
168
36
3
1
a
Individuals with pertussis may have had 1 or more of the listed complications. Data are for 1997-2000.
“Unvaccinated or incompletely vaccinated infants aged <12 months have the highest risk
for severe and life-threatening complications and death.”2
References: 1. CDC. MMWR. 2002;51(4):73-76. 2. CDC. MMWR. 2005;54(RR-14):1-16.
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Transmitting Pertussis to Infants
Is a Family Matter1
• Multicenter study in France,
Part-time
caretaker
Grandparent 2%
6%
Germany, Canada, US
• Study population: 95 infants ≤6
months of age with labconfirmed pertussis
• Household members were
Friend/Cousin
10%
responsible for 76%-83% of
transmission to infants in 44
cases where a source could be
identified
Mother
37%
Aunt/Uncle
10%
“Implementation of the ACIP recommendation for adult
and adolescent [Tdap] vaccination could substantially
reduce the burden of infant pertussis, if high coverage
rates among those in contact with young infants can be
achieved.”
Sibling
16%
Father
18%
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Reference: 1. Wendelboe AM, et al. Pediatr Infect Dis J. 2007;26(4):293-299.
154
ACIPa Recommendations for Use of
Tdapb in Adults and Adolescents
• All adults 19-64 years of age who have not already
received Tdap:1
– Single dose to those who received their last tetanus and diphtheria
toxoid (Td) vaccine ≥10 years ago
– Interval as short as 2 years since last Td may be used, especially
in settings of higher risk (outbreaks, contact with infants)
(CHANGED)
• All adolescents 11-18 years of age2
– Single dose of Tdap instead of Td
– Preferred timing is 11-12 years of age
a ACIP
= Advisory Committee on Immunization Practices. b Tdap = Tetanus, diphtheria, and acellular
pertussis vaccine.
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Reference: 1. CDC. MMWR. 2006;55(RR-17):1-37.
2. CDC.
MMWR. 2006;55(RR-3):1-43.
155
October 2010 – ACIP
Recommendations
• Tdap – for those over 65 years of age who
have not received Tdap previously, those
desiring Tdap, or those who to be in contact
with infants
– Ideally, 2 weeks before contact
• Interval has been removed for time between
Td and Tdap
• Also – Tdap may now be given (off-label) to
individuals 7 years of age (as a catch up) for
156
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children not immunized
The ACIP Recommends:
Build a Cocoon of Protection Around Infants1
• Tdap is recommended for all adults
who have or anticipate having
close contact with infants
<12 months of age
• Parents, grandparents (<65 years of age),
child-care providers, health-care personnel
• All should receive Tdap at least 2 weeks before beginning
contact with the infant
Reference: 1. CDC. MMWR. 2006;55(RR-17):1-37.
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ACIP Recommendations: Tdap for Mothers
• Women are encouraged to receive a single dose
of Tdap before conception if they have not
already received Tdap1
– Maternal antibody affords only limited (<2 months)
protection for the infant2,3
• For mothers who have not already received Tdap,
Tdap is recommended “as soon as feasible” in the
immediate postpartum period1
– Vaccination should occur before discharge from the
hospital or birthing center
References: 1. CDC. MMWR. 2008;57(RR-4):1-56. 2. Healy CM, et al. J Infect Dis. 2004;190(2):335-340. 3. Shakib
JH, et al. J Perinatol. 2010;30(2):93-97.
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New 2013
• Tdap with each pregnancy
• Tdap may be administered any time during
pregnancy, but vaccination during the third
trimester would provide the highest
concentration of maternal antibodies to be
transferred closer to birth
• Regardless of interval and previous
vaccination with Tdap
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm accessed 05-01-2013
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Tdap Issue Remaining
• What to do with individuals who have
received Tdap and are in need of another
Td vs. Tdap
• Tdap revaccination (June 2013)
– Meeting agenda for June 2013
– Decided NOT to universally recommend for
all, other than pregnant women
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Diagnostic Tests for Pertussis
(Regan-Lowe, BordetGengou)
 PCR
 Serologic tests
 Increased WBC
with an absolute
lymphocytosis
 DFA—variable
sensitivity/specificity
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Copyright © 2005 Nucleus Medical Art. All rights reserved. www.nucleusinc.com.
 NP culture on
special media
Treatment of Cases and
Chemoprophylaxis of Close
Contacts
 Erythromycin estolate or erythromycin ethylsuccinate
(EES) 40-50 mg/kg/day (max 2 g/day) in 2-4 divided
doses for 7-14 days1*
 Azithromycin 10-12 mg/kg/day (max 500mg/day)
1 dose/day for 5 days†
 Clarithromycin 15-20 mg/kg/day (max 1g/day) in 2
divided doses for 7 days
Reference:
1. Halperin SA. Pertussis Control in Canada [letter]. CMAJ. 2003;168(11):1389-1390.
* Use caution when using macrolides, especially erythromycin, in infants less than 2 weeks old.
† Azithromycin may be given as 10-12 mg/kg/day (max 500 mg/day) on day 1 and 5 mg/kg/day (max 250 mg/day) on days 25.
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Treatment of Cases and Chemoprophylaxis
of Close Contacts (cont’d)
• For patients allergic to macrolides:
– Trimethoprim-sulfamethoxazole 8mg TMP/40mg
SMX/kg/day (max 320mg TMP/1600mg/day) in 2
divided doses for 14 days1
• All of these agents reduce transmission of B pertussis
and ameliorate early symptoms2
• No antibiotic lessens the severity or shortens the
duration of cough in patients who are already
experiencing paroxysmal episodes1
• Penicillins/cephalosporins are not effective
References:
1. Edwards KM, et al. In: Plotkin SA, et al, eds. Vaccines. 1999:293-344.
1632005.
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2014
2. CDC. The Pink Book, 7th ed. 2002:75-88. Available
at: www.cdc.gov/nip/publications/pink/pert.pdf.
Accessed March 15,
Websites with
Vaccine Information
•
•
•
•
•
www.pertussis.com
www.cdc.gov/nip/vacsafe
www.cispimmunize.org
www.vaccine.chop.edu
www.vaccineprotection.com
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Stridor
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Stridor
• Few conditions in pediatrics are
as emergent and potentially life
threatening as an upper airway
obstruction
• Rapid identification and treatment
is essential
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Differential Diagnosis for Stridor
• Differential
– Laryngotracheobronchitis (croup)
– Mechanical obstruction (birth)
– Foreign body aspiration
– Peritonsillar abscess
– Epiglottitis
– Angioedema
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Croup
• Causes:
– Usually caused by a virus
– RSV, Parainfluenza or Rhinovirus
• Characteristics:
– Inflammation and edema of the pharynx and
upper airways
– Narrowing of the subglottic region
– + laryngospasm is frequently seen
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Croup
Subglottic narrowing
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Croup
• Presentation:
– Mild URI symptoms x 24 – 48 hours
• Rhinorrhea, cough, low grade fever, sore
throat
– Followed by a sudden onset of:
• Croupy cough, hoarseness of the voice and
stridor
– Stridor usually begins when the child
awakens suddenly from a nap or during
the night with a Wright,
fever
170
2014
Croup
• Presentation:
– May have wheezing on auscultation
– Suprasternal and subcostal retractions are most
common
– Tachycardia and tachypnea are frequently
present
– Hypoxemia may occur
– Severity and course varies significantly but
illness usually lasts about 3 days – 1 week
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Croup
• Treatment:
– Exposure to a cool night; child often improves on
the way to the ED
– Humidification or mist may be helpful
– Aerosolized racemic epinephrine can be helpful
• Very short acting agent delivered via nebulizer
– Nebulizer with albuterol or beta 2 agonist may
offer some benefit
– Inhaled corticosteroids/prednisone is frequently
beneficial
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Treatment
• Symptomatic treatment is the most
common treatment
– Increased fluids
– Cool mist vaporizer to thin the
secretions
– Tilting the child’s mattress up may be
beneficial
• Antibiotics are not helpful
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Severe Croup
• Airway management may be
essential
• Possibilities includes tracheostomy
vs. intubation depending upon
severity
– Rarely done any longer although may be
needed if child is severe
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Pneumonia
• Definition: Acute infection of the lung
parenchyma
• Can occur as a result of:
– Aspiration
– Viruses
– Bacteria
• Children < than 4 years
– Consider: RSV and parainfluenza
– Consider S. pneumoniae and H. influenzae
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Pneumonia
• Children > 5 years
– Mycoplasma, S. pneumoniae, Chlamydia
pneumoniae
• Physical Examination
– Vital signs
– Respiratory distress
– Auscultate lungs (egophony, bronchophony)
– Palpate for tactile fremitus
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Pneumonia
• Diagnostic
– Chest Xray is recommended for all
suspected cases of pneumonia
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Treatment of CAP
• < 5 years of age
– Presumed bacterial pneumonia
• Amoxicillin (90 mg/kg/day) in two divided doses OR
• Amoxicillin/clavulanate (90mg/kg/day) in two divided
doses
– Presumed atypical pneumonia
• Azithromycin (10 mg/kg on day followed by 5 mg/kg/day
on days 2-5)
• Clarithromycin (15mg/kg/day) in two divided doses x 7-14
days OR
• Erythromycin (40 mg/kg/day) in four divided doses
http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed
178
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05-01-2013
Treatment of CAP
• > 5 years of age
– Presumed bacterial pneumonia
• Amoxicillin (90 mg/kg/day) in two divided doses OR
• Amoxicillin/clavulanate (90mg/kg/day) in two divided doses
• Consider adding macrolide is unclear etiology
– Presumed atypical pneumonia
• Azithromycin (10 mg/kg on day followed by 5 mg/kg/day on days 2-5)
• Clarithromycin (15mg/kg/day) in two divided doses x 7-14 days OR
• Doxycycline for children > 7 – 8 years of age
http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed
179
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05-01-2013
Chest Pain
• Chest pain in children and adolescents
rarely has a cardiac etiology
• Most frequent causes
– Musculoskeletal injury vs. overuse
– Gastrointestinal (i.e. reflux)
– Lung/pleural etiology
– Psychogenic causes
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Cause of Chest Pain in Children
• Precordial Catch – (Texidor’s twinge)
– Most common cause of chest pain
– An innocent cause of chest pain
• Very typical history:
–
–
–
–
–
–
–
Sporadic (entirely random)
LSB (always same place)
Quality – sharp
Radiation: fingerpoint
Mild – severe
Lasts < 2 minutes
Respirations make it worse!!
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Cardiac Causes of Chest Pain
• Congenital heart conditions i.e.
cardiomyopathies
• Arrhythmias must also be considered
• Pericarditis vs. myocarditis must also be
considered
• Important:
– Comprehensive history and physical
examination
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Murmurs
• Innocent murmurs will be heard in up to
50% of school aged children
• Goal to make sure that you do not miss a
serious cardiac anomaly
• Important questions:
– Any sob with exercise?
– Any dizziness or syncope with exercise?
– Any family history of sudden cardiac death?
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Characteristics of
Benign Murmurs
•
•
•
•
•
•
•
•
No radiation
Systolic
Grade < III
Does not interfere with S1 and S2
Decreases with sitting or standing
Equal femoral and radial pulses
Normal PMI
Normal history and physical examination
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Characteristics of Pathologic
Murmurs
•
•
•
•
•
•
•
•
Radiation
Diastolic
Grade > IV
Interferes with S1 and/or S2
Increases with sitting or standing
Unequal femoral and/or radial pulses
Displaced PMI
Abnormal history
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Work – up for
Pathologic Murmur
• Cardiac consultation
• Echocardiogram
• If HCM is suspected, must deny sports
participation pending additional work-up
– Increases with standing
– Systolic in nature
– Often accompanied by shortness of breath
with exercise
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GI/GU
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Acute vs. Chronic
Abdominal Pain
• Acute gastroenteritis – number one
cause of acute abdominal pain in
children
• Other causes of acute pain:
– RLL and LLL pneumonia, constipation,
UTI, appendicitis, mittelschmerz, ectopic
pregnancy and ovarian cysts
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Causes of Chronic
or Recurrent Pain
•
•
•
•
•
Constipation
Musculoskeletal pain
Lactose intolerance vs. celiac disease
Colitis vs. Crohn’s
IBS
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Diarrhea
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Statistics
• Common complaint worldwide
– Millions of individuals develop diarrhea every year
• Young and old individuals at increased risk from
this condition
– Increased risk of dehydration
– Increased risk of death
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Pathophysiology
• 4 basic mechanisms causing diarrhea
– Retention of water within the intestine
• Malabsorptive syndrome; lactose intolerance
• Maalox can produce diarrhea through this mechanism
– Excessive secretion of water and electrolytes into the
intestinal lumen
• Cholera; E. Coli, Crohn’s disease, laxatives
– Release of protein and fluid into the intestinal mucosa
• Ulcerative colitis, Crohn’s disease, Infections
– Altered intestinal motility resulting in rapid transport through
the colon
• IBS, Scleroderma
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Acute Diarrhea
• Cause: most likely to be an infectious agent
– Most will resolve on own
– If diarrhea persists for 72 hours or more, is
associated with gross blood in stool, evaluation is
essential
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History
• Any other family/friends ill?
• Any recent trips/camping?
• Food intake?
– Any nonpasturized ciders?
– Any beef?
– Uncooked meats?
– Mayonnaise?
• Medications?
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Symptoms
•
•
•
•
•
•
•
•
•
Sudden onset
Frequent bowel movements
Loose, watery stools
Bloody stools
Abdominal cramping
Thirst
Decreased urination
Dizziness
Fatigue
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Physical Examination
•
•
•
•
•
•
•
•
Generally unremarkable
Tachycardia
Poor turgor
Orthostatic signs
Hyperactive bowel sounds (borborygmi)
Tender abdomen
Heme positive stool, possibly (E. Coli)
Fecal impaction
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Acute Gastroenteritis
• Symptoms
– Abdominal pain described as colicky, diffuse,
crampy
– May have vomiting
– Headache
– Fever and chills
– Profuse diarrhea often helps to differentiate it from
appendicitis
• Please remember that 15% of children with an
appendicitis will have significant diarrhea
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Gastroenteritis
• Signs
– Temperature
– Diffuse tenderness
– No obturator, psoas or markle’s sign
– Dehydration
• No urination or tears in 8 hours constitutes
dehydration in children
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Gastroenteritis
• Diagnosis
– History and physical examination
– Fecal leukocytes
• Salmonella, Shigella, Amoeba and
Campylobacter all invade the intestinal mucosa
and therefore cause leukocytes
• Inflammatory bowel disease (Colitis, Crohn’s)
• E. coli, viral etiologies do not generally produce
these cells
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Gastroenteritis
• Stools for O&P
– Entamoeba histolytica
– Giardia lamblia
• Stools for C&S
– Salmonella or Shigella
– Need to request specific tests for E. Coli, Yersinia,
and Campylobacter
• C. difficile
– Previous antibiotic therapy
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Gastroenteritis
• Treatment
– Fluids
– BRATT diet
• Avoid lactose
– Antibiotics
• Depending upon the pathology-antibiotic regimen varies
– IV rehydration
– Hospitalization
– Anti-motility agents (controversial)
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Constipation
• Normal frequency of BM’s: 3 / day – 3 per
week
• Focus is shifting more toward comfort with
BM’s rather than number
• Most common GI complaint in the US
• Always ask regarding following:
– Weight loss, blood in stool, abdominal pain,
anorexia, vomiting, anemia
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Constipation
• Options for treatment
–Fiber intake
–Polyethylene glycol (Miralax)
–Lactulose
–Milk of Magnesia
–Behavioral modification
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203
Don...
Don is a 17yowm who presents with an 2 day
history of worsening abdominal pain. Woke him
from sleep today. Epigastric at onset. Now
seems lower in right side of abdomen.
Associated with nausea and vomiting for the
past 2 hours and a temp of 100. Denies bowel
changes, urinary symptoms.
Meds: none; Allergies: NKDA
What is going on with Don?
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Appendicitis
• Inflammation/Infection of the Appendix
– Can lead to ischemia and perforation of the
appendix
• Etiology
– Most common age: 10-19 years
– Incidence: 1.1/1000 Persons each year
– Males>females
– Whites>Nonwhites
– Summer-most common time of year
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– Midwest-highest incidence
205
Appendicitis
• Mortality and morbidity rates remain high
• Perforation rates: 17-40%
– Perforation has been known to occur within
1st 24-48 hours of the infection
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History of a patient with appendicitis
• Careful history is the most important aspect
– Individual is usually a teen or young adult
• Classic presentation: awakens in the night with
vague periumbilical pain
• Worsens over the period of 4 hours
• Subsides as it migrates to the RLQ
• Worsened with movement, deep respirations,
coughing
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Clinical Pearl
The presence of pain before
vomiting is highly suggestive
of appendicitis.
Diarrhea before pain is more
likely to be gastroenteritis.
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Physical Examination
• Abdominal Examination
– Tenderness at McBurney’s point
• 1/3 the distance between the anterior
iliac spine and the umbilicus
– Guarding
• Contraction of the abdominal walls
• Frequently present
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Physical Examination
• Rigidity
– Important predictor of appendicitis
– Involuntary spasm of the abdominal
musculature
– Caused by peritoneal inflammation
• Markle’s sign
– Heel-drop jarring test
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Physical Examination
• Rebound tenderness
– Press on area above the pain
– Suddenly withdraw fingers
• Rovsing’s Sign
– Pain felt in RLQ when examiner presses firmly in
the LLQ and suddenly withdraws
• Psoas Sign
– Patient is placed in a supine position
– Ask patient to life thigh against your hand that you
have placed above the
knee
211
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Physical Examination
• Obturator Sign
– May be or may not be positive
– Patient is positioned in supine position with
the right hip and knee flexed
– Internally rotate the right leg
• Internal Examination
– Consideration to an ovarian cyst
• Rectal Examination
– May be considered
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Laboratory/Radiologic Testing
• CBC with differential
– Normal wbc count doesn’t rule-out the diagnosis
– White blood cell count may actually decrease
– Look for wbc left shift
• Elevated wbc
• Elevated neutrophils
• Elevated bands
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Laboratory/Radiologic Testing
• Urinalysis
• CT Scan vs. Ultrasound
– Emerging evidence that US may be as effective
as CT scan for individuals with appendicitis
– Many hospitals are moving to US first approach
to reduce radiation exposure
http://www.sciencedaily.com/releases/2013/12/131202171811.htm accessed 05-01-2014
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UTI
• Gram negative bacilli are the most
common pathogens (Escherichia coli)
• Staphylococcus saprophyticus – more
likely in young, sexually active women
• Preschoolers and young children will likely
present with symptoms similar to an adult
– Dysuria, urgency, frequency
• Must r/o or consider pyelonephritis
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UTI
• Urinary dipstick findings
– Leukocytes
– Nitrites
– RBC’s
• Treatment
– Trimethoprim/sulfamethoxazole (8 – 10 mg/day of
trimethoprim
– Cefixime (Suprax) in children > 6 years
– Cefpodixime (Vantin)
– Treatment: 7 days –Wright,
10 days
216
2014
Enuresis
• Definition: involuntary urination at night after
5 years of age in girls and 6 years of age in
boys
– Small percentage have diurnal enuresis
• Differentials (particularly if dry in past)
– Urinary tract infection
– Emotional issues (divorce, new baby)
– Type 1 diabetes
– Neurologic abnormalities
– Constipation
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Enuresis
• Treatment Options
– Desmopressin (DDAVP )(Nasal spray no
longer approved for this indication)
– Tricyclic antidepressants (caution advised)
– Bed wetting alarm
– Bladder training
– Constipation treatments
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School Physical Examination
• Help to maintain the health and safety of
the young athlete by...
– Detecting conditions that may predispose to
injury (obesity, recurrent ankle sprains)
– Detect conditions that may be life threatening
(hypertrophic cardiomyopathy)
• Goal to not to exclude an individual from
sport’s participation
– But…to find any problems that might worsen
with particular activities
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Millions of Young Athletes
• Millions of young
athletes are
involved in a
variety of
activities
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220
Goals of the Preparticipation
Physical Examination
• Pre-participation physical is also not a
substitute for routine primary care
–However, the preparticipation
physical examination is the only
contact with a health care
provider for 78% of all athletes
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Kids Just Want to Have Some
Fun!!
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Frequency
• AAP recommends
examinations every 2 years
• Many schools have different
recommendations
http://www.emedicine.com/sports/TOPIC156.HTM#section~TimingFrequencyandType
sofEvaluations accessed 02-10-2010
223
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Preparticipation Physical
Examination
• Guidelines issued by AHA, AAFP and AAP
• Standardized forms recommended to
include history and physical examination
• Biggest concern
– Cardiac pathology
• Most common abnormality
– Orthopedic abnormality
http://pedsinreview.aappublications.org/cgi/content/extract/22/6/199 accessed 02-10-2010
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Sprains/strains
• Most frequently encountered in children:
– Ankles – number 1
– Fingers
– Knees
• Differentiation between various grades
– First degree: minimal pain, joint stable
– Second degree: severe pain, minimal joint
instability
– Third degree: severe pain and complete instability
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY,
NY: The McGraw-Hill Companies.
226
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Treatment of Ankle Sprains
• Grade I: ice, elevation, NSAIDs, ankle
brace, weight bearing may begin
immediately. D/C brace in 1 month.
• Grade II: ice, elevation, NSAIDs, ankle
brace, no weight bearing x 7 days
• Grade III: walking cast x 3 – 4 weeks, PT,
ankle brace
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY,
NY: The McGraw-Hill Companies.
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Fractures
• Most common in children:
– Fingers, toes, distal radius, clavicle, ankle
• Assessment
– Capillary refill
– Surrounding skin
– Sensation
• Treatment
– Stabilization, elevation, ice
– Casting
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Chondromalacia Patella
• Occurs mainly in adults but can occur in
adolescents
• Pain occurs when climbing stairs or going
from a squatting position to standing
• Diagnosis:
– Consider knee films to r/o subluxation of
the patella
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Treatment of
Chondromalacia Patella
• Decrease activities which require full
flexion of the knee and stress on the
patellofemoral joint
• RICE
• Quad muscle strengthening
• Physical therapy may be helpful
• Consider orthotics if needed
• NSAIDs as needed
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Osgood Schlatter Disease
• Most common in later childhood and early
adolescence
• Painful swelling and tenderness of the tibial
tuberosity
• Treatment:
– Decrease quad loading and bending
– RICE treatment protocol
– Quad and hamstring stretching
– NSAID as needed
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Neurologic
Conditions
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Headache
• Headaches are common in childhood and
adolescence
• Primary headaches account for 90+% of
all headaches:
– Migraine
– Tension
– Cluster
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Headache
• Indications for Headache Work-up
–Systemic symptoms
–Neurologic signs and symptoms
–Onset
–Older (< 5 or > 50)
–Previous headache
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Dodick DW. Adv Stud Med. 2003;3:87-92.
234
Treatment for Headaches
• Tension:
– NSAID or acetaminophen
– Rest and heat
• Migraine
– NSAID or acetaminophen
– Trigger Avoidance
– Triptan (rizatriptan and almotriptan approved
in children)
– Preventative therapies, as indicated
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Syncope
• Syncope: sudden loss of consciousness
with spontaneous recovery
• Majority of syncopal episodes in children
are benign however, must consider the
following
– Seizure activity
– Cardiac malformations/pathology
http://www.aafp.org/afp/20050601/tips/13.html
accessed 08-22-2008
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Syncope
http://www.aafp.org/afp/20050601/tips/13.html
accessed 08-22-2008
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Concussion Guidelines
http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013
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What Is A Concussion?
• A concussion is a disturbance in brain function caused
by a direct or indirect force to the head
• Results in a variety of non-specific signs and / or
symptoms and most often does not involve loss of
consciousness
• Should be suspected in the presence of any one or
more of the following:
– Symptoms (e.g., headache), or
– Physical signs (e.g., unsteadiness), or
– Impaired brain function (e.g. confusion) or
– Abnormal behavior (e.g.,
change in personality)239
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http://bjsm.bmj.com/content/47/5/259.full.pdf accessed 05-18-2013
Concussions
• Confusion and amnesia will occur
immediately after event
• Often accompanied by headache, dizziness,
nausea and/or vomiting
• Symptoms following a concussion may last
up to 3 months or longer
• Concussions are more likely to occur within
10 days of a previous concussion
http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013
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Concussion
Administer prior to season; administer immediately after injury.
Return to play when symptoms are consistent with baseline score
http://knowconcussion.org/wp-content/uploads/2011/06/graded_symptom_checklist.pdf
accessed 05-19-2013
241
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Return to Play
This tool is not used alone but provides guidance for return to play
Should NOT be returned to play on day of concussion
http://bjsm.bmj.com/content/47/5/259.full.pdf accessed 05-18-2013
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Dermatologic
Conditions
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Abscess
• Definition:
–Collection of pus in the cutaneous tissue
which results in a painful, erythematous,
fluctuant mass
• Most common locations
–Inguinal region, neck or back, axillary
region, vaginal
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Cutaneous Abscesses
• Pathogens
– Methicillin sensitive staphylococcus aureus
– Methicillin resistant staphylococcus aureus
• Treatment
– Incision and drainage is the treatment of choice
– Many recommend wound culture
– Antibiotics may be utilized but are not as
effective as I&D
– Warm soaks/compresses
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Verruca Vulgaris
• Common warts
• Benign lesions of the epidermis caused by a
virus
• Transmitted by touch and commonly appear at
sites of trauma, on the hands, around the
periungual regions from nail biting and on the
plantar surfaces of the feet
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Verruca Vulgaris
• Appearance
– Smooth, flesh colored papules which
evolve into a dome-shaped growth with
black dots on the surface
– Black dots are thrombosed capillaries
and can be visualized with a 15 blade
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Verruca Vulgaris
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Verruca Vulgaris
• Treatment
–
–
–
–
–
–
–
–
–
–
OTC product: salicylic acid topical (Compound W) or similar
OTC cryosurgery kit
Liquid nitrogen
Duct tape
Cryosurgery in office
Cimetidine
• Immunomodulatory effects at high dosages; effects varied
Imiquimod
Tretinoin type products
Electrocautery
Blunt dissection (plantar lesions)
249
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Urticaria
• Etiology
– Referred to as wheals or hives
– Causes: Foods, soaps, inhaled substances
– 20% of the population will have at least one
episode
– 2 types: Acute and Chronic
• Acute is most common - lasting days to weeks
(Cause is most often identified)
• Chronic: Lasts more than 6 weeks (Cause is
rarely identified)
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Urticaria
• Symptoms
– Hives itch!!!!!
– Red plaques
• Signs
– Red lesions which vary in size from 2 - 4 mm
– Blanche with palpation
• Diagnosis
– History and physical examination
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Urticaria
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Urticaria
• Plan
–Therapeutic
• Stop medications if possible
• Stop suspected foods or drinks
• Cool compresses
• Antihistamines/H2RA
• Prednisone
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Urticaria
• Plan
–Educational
• Avoid causes
• Educate regarding possible etiology
• Discuss side effects of
antihistamines (sedation)
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Impetigo
• Contagious, superficial skin infection
• Caused by staphylococci or streptococci
– Staph is the most common cause
– Makes entrance through small cut or abrasion
– Resides frequently in the nasopharynx
• Spread by contact
• More common in children, particularly on the
nose, mouth, limbs
– Self-limiting but if untreated may last weeks to
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Impetigo
• Symptoms:
– Rash that will not go away
– Begins as a small area and then increases in size
– Yellow, crusted draining lesions
• Physical Examination Findings
– Small vesicle that erupts and becomes yellowbrown
– Initially, looks like an inner tube
– Crust appears and if removed, is bright red and
256
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inflamed
Impetigo
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Impetigo
• Physical Examination Findings
– 2-8 cm in size
• Diagnosis
– Diagnostic:
• Culture – Today, must absolutely consider
MRSA
– Therapeutic:
• Mupirocin topical (Bactroban) or retapamulin
topical (Altabax)
• 1st generation cephalopsporin vs. TMP/SMX
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Impetigo
• Educational
–Good handwashing and hygiene
–No school/daycare for 24 - 48 hours
–Wash sheets and pillowcases
–Monitor for serious sequelae
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Clinical Practice Guidelines by
the Infectious Diseases Society
of America for the Treatment of
Methicillin –Resistant
Staphylococcus aureus
Infections in Adults and Children:
Executive Summary
Liu, Catherine et. al. MRSA Treatment Guidelines CID 2011:52 (1 February) 285-292
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Treatment for Uncomplicated
CA-MRSA
• No significant risk factors for adverse
outcomes
• I&D is the treatment of choice
• Antibiotics are not necessary
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Antibiotics Indicated
• Abscesses associated with the following:
– Severe or extensive disease
– Rapid progression in presence of cellulitis
– Signs and symptoms of systemic illness
– Associated comorbidities or
immunosuppression
– Extremes of age
– Abscess in area unable to be drained
– Lack of response to I&D alone
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Statistics/Treatment in My
Community
• 37% of staph infection at DHMC – MRSA
• Nationally, approximately 31% are MRSA
• CA-MRSA antibiotic susceptibility
– 50% will be resistant to clindamycin
• Trimethoprim/sulfamethoxazole (Bactrim) has
best coverage/sensitivity: 96-98%
– Important for clinicians to obtain own antibiogram
for communities in which you service
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Treatment of CA-MRSA
• Obtain culture
• Should consider local antibiograms in selection
of antimicrobials
• Skin infections:
– Consider beta-lactam (PCN or Cephalo) in an
individual with mild infection and low rates of CAMRSA in your community (generally thought of as <
10 – 15%)
Guilbeau, J.R. and Fordham, P.N. Evidence-Based management and Treatment of Outpatient CommunityAssociated MRSA. The Journal for Nurse Practitioners. 2010; Vol 6(2):140-145
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Treatment of CA - MRSA
•
•
•
•
•
TMP/SMX
Tetracycline (doxycycline or minocycline)
Clindamycin
Linezolid
When CA-MRSA and streptococcus coverage
is needed:
– Clindamycin alone or….
– TMP/SMX with amoxicillin (or similar)
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Rifampin
• No longer recommended as a single agent
or for adjunctive therapy for the treatment
of skin and soft tissue infections
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Children
• Simple, uncomplicated impetigo:
– Mupirocin 2% topical ointment
• Avoid TCN or similar in children < 8 years
of age
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Treatment and Eradication
Strategies: Recurrent infections
• GOOD handwashing
• Treatment with TMP/SMX,clinda, TCN,
Linezolid
• Bathe with disinfectants
– Hibiclens, phisodex, clorox bleach
• Utilize topical disinfectants
– Purell
– Mupirocin – seeing resistance
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Carriage of CA-MRSA
• Treatment recommended for individuals with
recurrent infection
– Consider ID consult before treatment
– Mupirocin 2% each nostril two times daily x 5 – 10
days along with daily chlorhexidine 4% bath for 514 days
– Alternative: 1 teaspoon of bleach per gallon of
water (1/4 cup per ¼ tub); 15 minutes two times
weekly for 3 months
– Oral antibiotics are not indicated for decolonization
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Bites and Stings
• Insect Sting
– Reaction to wasp or yellow-jacket sting can begin
within minutes – up to 60 minutes
– Anaphylaxis can occur within minutes in the
individual with allergy
• Treatment:
– Remove stinger, if present
– Oral antihistamine
– Ice pack and elevate
– Anaphylaxis history: Epi Pen with instructions
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Erythema Chronicum Migrans
• Etiology
– Caused by a spirochete called Borrelia Borgdorferi
– Transmitted by the bite of certain ticks (deer,
white-footed mouse)
– 1st cases were in 1975 in Lyme, Connecticut
– Occurs in stages and affects many systems
– Children more often affected than adults
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This is NOT a Lyme Bearing Tick
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Lyme Bearing Tick
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Erythema Chronicum Migrans
• Symptoms
– 3-21 days after bite
– Stage 1
• Rash (present in 72-80% of cases)-slightly itchy
• Lasts 3-4 weeks
• Mild flu like symptoms (50% of time)
• Migratory joint pain
– Stage 2
• Neurological and cardiac symptoms
– Stage 3
• Arthritis, chronic neurological symptoms
• Make take years to get
to this stage
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Erythema Chronicum Migrans
• Signs
– Rash: Stage 1
• Begins as a papule at the site of the bite
• Flat, blanches with pressure
• Expands to form a ring of central clearing
• No scaling
• Slightly tender
– Arthralgias: Stage 2
• Asymmetric joint erythema, warmth, edema
• Knee is most common location
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Summer 2009
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Erythema Migrans
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Erythema Migrans
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Erythema Chronicum Migrans
• Signs
– Systemic symptoms: Stage 3
• Facial palsy
• Meningitis
• Carditis
• Diagnosis
– R/O Ringworm (Tinea Corporis)
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Erythema Chronicum Migrans
• Plan
– Diagnostic:
• Sed rate: normal until stage 2
• Lyme Titer
– IGM: Appears first: 3-6 weeks after infection begins
– IGG: Positive in blood for 16 months
– High rate of false negatives early in the disease
– Lyme Western Blot
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Erythema Chronicum Migrans
• Plan
–Therapeutic
• Amoxicillin 500mg tid x 21 days
• Doxycycline 100 mg 1 po bid x 21
days
• If in endemic area and tick is partially
engorged, may treat with doxycycline
200 mg x 1 dose with food
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281
Pityriasis Rosea
• Etiology
– Common, benign skin eruption
– Etiology unknown but believed to be viral
– Small epidemics occur at frat houses and military
bases
– Females more frequently affected
– 75% occur in individuals between 10 and 35;
higheset incidence: adolescents
– 2% have a recurrence
– Most common during
winter
months
282
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2014
Pityriasis Rosea
• Symptoms
–
–
–
–
Rash initially begins as a herald patch
Often mistaken for ringworm
29% have a recent history of a viral infection
Asymptomatic, salmon colored, slightly itchy rash
• Signs
– Prodrome of malaise, sore throat, and fever may precede
– Herald patch: 2-10cm oval-round lesion appears first
– Most common location is the trunk or proximal extremities
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Pityriasis Rosea
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Pityriasis Rosea
• Signs
– Eruptive phase
• Small lesions appear over a period of 1-2
weeks
–Fine, wrinkled scale
–Symmetric
–Along skin lines
–Looks like a drooping pine tree
–Few lesions-hundreds
–Lesions are longest in horizontal dimension
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Pityriasis Rosea
• Signs (continued)
– 7-14 days after the herald patch
– Lesions are on the trunk and proximal
extremities
– Can also be on the face
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Pityriasis Rosea
• Diagnosis
– History and physical examination
• Plan
– Diagnostic
• Can do a punch biopsy if etiology uncertain
–Pathology is often nondiagnostic
–Report: spongiosis and perivascular round
cell infiltrate
• Consider an RPR to rule-out syphilis
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Pityriasis Rosea
• Plan
– Therapeutic
• Antihistamine
• Topical steroids
• Short course of steroids although, may not respond
• Sun exposure
• Moisturize
– Educational
• Benign condition that will resolve on own
– May take 3 months to completely resolve
• No known effects on the pregnant woman
• Reassurance
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Molluscum Contagiosum
• Infection caused by the pox-virus
• Most commonly seen on the face, trunk and
axillae
• Self-limiting
• Spread by auto-inoculation
• Incubation period: 2-7 weeks after exposure
• Contagious until gone
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Molluscum Contagiosum
• Asymptomatic lumps
• May have 1 - hundreds
• Physical Examination
– 2-5mm papule with an umbilicated center
– Flesh toned - white in color
– Most often around the eye in children
– Scaling and erythema around the periphery of
the lesion is not unusual
– If in the genital area of a child-should consider
sexual abuse
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Molluscum Contagiosum
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Molluscum Contagiosum
• Plan
– Diagnostic: None or KOH prep looking for
inclusion bodies
– Therapeutic: Conservative treatment is the best
for children
• Curettage
• Cryosurgery
• Tretinoin
• Salicylic Acid (Occlusal)
• Laser
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• TCA
Molluscum Contagiosum
• Plan
– Educational
• May resolve on own in 6 - 9 months
• Contagious until lesions are gone
• Benign
• Recurrence very common
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Scabies
• Etiology
–Contagious disease caused by a
mite
–Common among school children
–Adult mite is 1/3 mm long
–Front two pairs of legs bear clawshaped suckers
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Scabies
• Etiology
– Infestation begins when a female mite arrives on
the skin surface
– Within an hour, it burrows into the stratum
corneum
• Lives for 30 days
• Eggs are laid at the rate of 2-3 each day
• Fecal pellets are deposited in the burrow behind the
advancing female mite
• (Scybala)-feces are dark oval masses that are irritating
and often responsible for itching
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Scabies
• Etiology
– Transmitted by direct skin contact with
infested person either through clothing
or bed linen
– Eruption generally begins within 4 – 6
weeks after initial contact
– Can live for days in home after leaving
skin
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Scabies
• Symptoms
– Minor itching at first which progresses
– Itching is worse at night (this is characteristic of
scabies)
• Signs
– Erythematous papules and vesicles
– Often on the hands, wrists, extensor surfaces of
the elbows and knees, buttocks
– Burrows are often present; May see a black dot
at the end of the burrow
– Infants: wide spread involvement
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Scabies
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Scabies
•
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Scabies
• Diagnosis
–Scraping to look for mite, eggs or
feces
• Plan
–Diagnostic: Scraping
–Therapeutic
• Permethrin 5% cream
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• Plan
Scabies
– Therapeutic
• Sulfur (6% in petroleum or cold cream qd x 3
days)
• Antihistamine
– Educational
• Cut nails short
• Scratching spreads the mites
• Itching can last for weeks
• Treat all family members
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Scabies
• Plan
–Educational
• Wash all clothing, towels and bed
linen
• Do not need to wash carpeting
• Consider animal bathing
• Bag stuffed animals x 1-2 weeks
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Lice/Pediculosis
• Caused by parasites that are found on the
heads of individuals – most often children
• Very common in 3 – 10 year old individuals
• 1 out of 10 children will contract while in
school
• Lice/eggs are most commonly located on
the scalp behind the ears and near the
neckline at the back of the neck
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Treatment
• Treat hair with pediculicide and comb nits
daily
• Machine wash all in hot water cycle (130
degrees F or dry clean items
• Put items which can’t be cleaned into a
plastic bag and seal it for two weeks
• Soak combs and brushes for one hour in
rubbing alcohol or Lysol
• Vacuum the floor and furniture
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Prescription Lice Products
Age
indication
Dosage
Time of
application
Benzyl
alcohol, 5%
(Ulesfia)1
Malathion, 0.5%
(Ovide)2
Spinosad,
0.9%
(Natroba)3
Ivermectin,
0.5%
(Sklice Lotion)4
Lindane,
1%5
≥6 mo
Safety not shown
<6 y
≥4 y
≥6 mo
Use w/caution
in those <110 lb
4-48 oz
(varies with
hair length)
2-oz bottles;
apply enough to
wet hair and
scalp
Up to 120 mL
(1 bottle)
depending on
hair length
Up to 120 mL
( 4-oz tube)
1-2 oz
depending on
hair length and
density
10 min;
repeat
treatment
after 7 d
8–12 hrs; repeat
treatment in
7-9 d if lice
present
10 minutes;
repeat
treatment in
7 d if lice
present
10 minutes; tube
is intended for
single use only;
consult HCP
prior to
re-treatment
4 min;
do not re-treat
References: 1. Ulesfia Prescribing Information. Atlanta, GA: Shionogi Pharma, 2010. 2. Ovide Prescribing Information. Hawthorne,
NY: Taro Pharmaceuticals, 2011. 3. Natroba Prescribing Information. Carmel, IN, ParaPRO, 2011. 4. Sklice Lotion Prescribing
Information. Swiftwater, PA: Sanofi Pasteur Inc., 2012. 5. Lindane Prescribing Information. Morton Grove, IL: Morton Grove
Pharmaceuticals, 2005.
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17
Keeping Kids in School
• The AAP and National Association of School Nurses state:
No healthy child should be allowed to miss school time
because of head lice1,2
• “No-nit” policies for return to school should be abandoned1,2
• School-based head lice screening programs have not had a
significant effect on incidence of head lice in schools and are not
cost-effective2
• School nurses in concert with other health-care providers should
become involved in helping school districts develop evidencebased policies1
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting, position statement, National Association of School
Nurses, 2011. http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/
NASNPositionStatementsFullView/tabid/462/ArticleId/40/Pediculosis-Management-in-the-School-Setting-Revised-2011.
Accessed July 16, 2012. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
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22
Candidiasis/Tinea Infection
• Infection frequently caused by Candida
albicans which invades the epidermis
when there is a break in the skin and there
is excessive moisture and heat
• Candida always involves the skin folds
• Orally: thrush (Oral candidiasis)
– Treatment: Mycelex troches, Nystatin
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Candidiasis/Tinea
• Diaper: satellite lesions with well-defined
beefy red rash
– Treatment: Nystatin cream
• Tinea Cruris (male inguinal region)
– Clotrimazole
– Miconazole
– Keep clean and dry
– Consider treating the tinea pedis
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Atopic Dermatitis
• Etiology
– Most common inflammatory skin disease if
childhood
– Affects 10-12% of all children
– Caused by an inflammation in response to an
allergen, chemical or an unidentified etiology
– Often occurs in an individual with a family history
of allergies
– 50% of eczematous children will develop allergic
rhinitis, asthma
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Etiology
• High levels of serum IgE are common
– Higher the levels of IgE-more severe the case
• Proliferation of T-helper 2 cells; Th-2 cells
produce cytokines
• Cytokines cause an inflammatory
response in the skin
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Atopic Dermatitis
• Signs
– Pruritic, erythematous dry patches
– Cracking and fissuring
– Lichenification (Thickening of the skin)
– Excoriations (Caused by scratching)
– Diffuse borders (different than psoriasis)
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Diagnosis?
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Common Locations
• Infants: scalp, face, and
extensors
• Children: neck, flexor folds,
feet
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Atopic Dermatitis
• Plan
–Diagnostic
• None
–Therapeutic
• Lubrication: Most important part
• Perform multiple times daily; particularly
after a bath
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Atopic Dermatitis
• Therapeutic
• Limit number of baths or showers
– Avoid harsh soaps
•
•
•
•
Antihistamines: OTC or prescription
Low potency topical corticosteroids
Immunomodulator (Elidel or Protopic)
Avoids soaps, bath gels, bubble baths, shower
gels
• Intralesional injections of corticosteroids
• Oral corticosteroids
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Atopic Dermatitis
• Educational
– Explain the chronic nature of this condition
– Review medications and why they are utilized
– Avoid harsh soaps
– Monitor for yellow discharge-often results in
impetigo
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Acne Vulgaris
• Etiology
– Disease involving the pilosebaceous unit
– Most frequent and intense where sebaceous
glands are the largest
– Acne begins when sebum production increases
– Propionibacterium acnes proliferates in the
sebum
– P. acnes is a normal skin resident but can cause
significant inflammatory lesions when trapped in
skin
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Diagnosis?
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• Diagnosis
Acne Vulgaris
– History and physical examination
• Plan
– Diagnostic: None
– Therapeutic
•
•
•
•
•
•
Benzoyl Peroxide
Topical Antibiotics
Oral Antibiotics
Tretinoin
OCPs
Isotretinoin (Accutane)
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Chickenpox (Varicella)
•
•
•
•
•
•
Highly contagious viral infection
Varicella-zoster virus
Affects most children before puberty
Peak incidence is March-May
Spread via airborne droplets or vesicular fluid
Contagious for 1 - 2 days before rash until lesions
crust
• Incubation period-up to 21 days
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Chickenpox (Varicella)
• No prodrome or very mild
• Rash usually begins on the trunk and scalp
and then spreads peripherally
• Moderate to intense itching
• Fever: 101-105
• Lesions erupt for 4 days
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Chickenpox (Varicella)
• Physical Examination Findings
– Lesions 2-4 mm papule (rose petal)
– Thin walled clear vesicle (dew drop)
– Vesicle becomes umbilicated within 8-12 hours
– Followed by crusts
– Lesions are in all stages – hallmark of this
disease
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Chicken Pox
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Chickenpox (Varicella)
• Plan
– Diagnosis: None
– Therapeutic: Symptomatic Treatment
• NO ASPIRIN
• Clip Nails
• Caladryl or Benadryl
• Antiviral
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Chickenpox (Varicella)
• Plan
– Education:
• Call immediately for worsening of symptoms
• Contagious until all lesions crust
• Caution of pregnant women and others
without immunity
• Monitor for secondary complications
• Prevention: Varicella vaccine
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Ringworm
• Tinea Corporis
– Caused by a fungus / dermatophytes
which lives on the dead layer of the
outer skin
– Can also be transmitted to an individual
from an animal
– Increased sweating can promote fungal
growth
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Tinea Corporis
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Tinea Corporis
• Produces
characteristic rash
• Treatment
– Pink
– Scaly
– Round
– May be 3 – 5 cm in
size
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– Antifungal – topical
• Miconazole
• Clotrimazole
– Avoid touching as it
is very contagious
– No contact sports x
48 hours into
treatment
328
Herpes Simplex Virus
• HSV 1 and 2
• Spread in 3 manners
– Respiratory droplets
– Contact with an active lesion
– Contact with fluid such as saliva
• 90% of primary infections are asymptomatic
• Symptoms usually occur 3 - 7 days after
contact
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Herpes Simplex Virus
• Symptoms
–Tenderness, pain, paresthesia,
burning, swollen glands,
headache, fever, irritability,
decreased appetite, drooling
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Herpes Simplex Virus
• Physical Examination Findings
– Grouped vesicles on an erythematous base
– Gingivostomatitis: Erythematous, edematous
gingiva that bleed easily with small, yellow
ulcerations
• Yellowish-white debris develops on mucosa
• Halitosis
• Lymphadenopathy
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Herpes Simplex Virus
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Herpetic Gingivostomatitis
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Herpes Simplex Virus
• Plan
– Diagnostic
• Viral Culture
• HSV IgG & IgM serum antibodies
• Most accurate: HerpeSelect
– Therapeutic
• Antiviral
• Pain reliever
• Cool rinses
• Oragel
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Herpes Simplex Virus
• Plan
– Educational:
• Prevent contact with infected individuals
• Discussion regarding asymptomatic shedding
• Prevent recurrences
• Call for worsening of symptoms (I.e. inability to
drink, no urination x 8 hours)
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Roseola
• Viral infection caused by HHV6
(human herpes virus – 6)
• Most common ages: 3 months – 4
years
• Incubation period: 5 – 15 days
• Fever up to 105 will precede the rash
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http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm
accessed 03-01-2010
Roseola
• Fever - up to 3 – 5 days
• The fever falls quickly – usually between
day 2 - 4
• Rash will first appear on the trunk and
then spreads to the limbs, neck, and face
• Rash lasts from hours to 2 days
• May be associated with a febrile seizure
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http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm
accessed 03-01-2010
Roseola
• Treatment
–Ibuprofen
–Acetaminophen
–Tepid baths
• Cautiously with
fever
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http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm
accessed 03-01-2010
Fifth’s Disease
(Erythema Infectiosum)
• Human Parvovirus B19
– Occurs in epidemics
– Occurs year round: Peak incidence is late winter and
early spring
• Most common in individuals between 5-15years of
age
– Period of communicability believed to be from exposure
to outbreak of rash
– Incubation period: 5-10 days
– Can cause harm to pregnant women and individuals who
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are immunocompromised
Fifth’s Disease
(Erythema Infectiosum)
• Low grade temp, malaise, sore throat
– May occur but are less common
• 3 distinct phases
– Facial redness for up to 4 days
– Fishnet like rash within 2 days after facial redness
– Fever, itching, and petecchiae
• Petecchiae stop abruptly at the wrists and
ankles
– Hands and feet only
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Fifth’s Disease
(Erythema Infectiosum)
• Physical Examination Findings
– Low grade temperature
– Erythematous cheeks
• Nontender and well-defined borders
– Netlike rash
• Erythematous lesions with peripheral white rims
• Rash-remits and recurs over 2 week period
– Petecchiae on hands
and feet
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• Fifth’s Disease
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Fifth’s Disease
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Fifth’s Disease
(Erythema Infectiosum)
• Diagnosis/Plan
– Parvovirus IgM and IgG
– IgM=Miserable and is present in the blood
from the onset up to 6 months
– IgG=Gone and is present beginning at day
8 of infection and lasts for a lifetime
– CBC-May show a decreased wbc count
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Fifth’s Disease (Erythema
Infectiosum)
• Diagnosis/Plan
– Was contagious before rash appeared therefore, no
isolation needed
• Spread via respiratory droplets
– Symptomatic treatment
– Patient education-I.e. contagion, handwashing
– Can cause aplastic crisis in individuals with hemolytic
anemias
– Concern regarding: miscarriage, fetal hydrops
– Adults: arthralgias
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Hand, Foot, and Mouth Disease
(Coxsackie Virus)
•
•
•
•
•
Caused by the coxsackie virus A16 and now…A6
Most common in children
2-6 day incubation period
Occurs most often in late summer-early fall
Symptoms
– Low grade fever, sore throat, and generalized malaise
– Last for 1-2 days and precede the skin lesions
– 20% of children will experience lymphadenopathy
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cdc.gov
• From November 7, 2011, to February 29, 2012, CDC received reports of 63
persons with signs and symptoms of HFMD or with fever and atypical rash in
Alabama (38 cases), California (seven), Connecticut (one), and Nevada
(17).
• Coxsackievirus A6 (CVA6) was detected in 25 (74%) of those 34 patients
• Rash and fever were more severe, and hospitalization was more common
than with typical HFMD.
• Signs of HFMD included fever (48 patients [76%]); rash on the hands or feet,
or in the mouth (42 [67%]); and rash on the arms or legs (29 [46%]), face (26
[41%]), buttocks (22 [35%]), and trunk (12 [19%])
• Of 46 patients with rash variables reported, the rash typically was
maculopapular; vesicles were reported in 32 (70%) patients
• Of the 63 patients, 51 (81%) sought care from a clinician, and 12 (19%) were
hospitalized. Reasons for hospitalization varied and included dehydration
and/or severe pain
• No deaths were reported
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Hand, Foot, and Mouth Disease –
A6
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http://wwwnc.cdc.gov/eid/article/18/2/11-1147-f1.htm accessed 05-01-2013
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Hand, Foot, and Mouth Disease
(Coxsackie Virus)
• Physical Examination Findings
– Oral lesions are usually the first to appear
• 90% will have
– Look like canker sores; yellow ulcers with red halos
– Small and not too painful
– Within 24 hours, lesions appear on the hands and
feet
• 3-7 mm, red, flat, macular lesions that rapidly become
pale, white and oval with a surrounding red halo
• Resolve within 7 days
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Hand, Foot, and Mouth Disease
(Coxsackie Virus)
• Physical Examination Findings
–Hand/feet lesions
• As they evolve – may evolve to form
small thick gray vesicles on a red
base
• May feel like slivers or be itchy
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Hand Foot and Mouth Disease
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Hand Foot and Mouth Disease
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Hand, Foot, and Mouth Disease
(Coxsackie Virus)
• Plan
–Diagnostic: None
–Therapeutic
• Tylenol
• Warm baths
• Oragel or diphenhydramine/Maalox
• Magic mouthwash
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Hand, Foot, and Mouth Disease
(Coxsackie Virus)
• Plan
– Educational
• Very contagious (2d before -2 days after eruption
begins)
• Entire illness usually lasts from 2 days – 1 week
• Reassurance
• No scarring
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Kawasaki Disease
• Characterized by an systemic vasculitis
throughout the body
• Seventy five percent of patients are under
five years old
• It is more common in boys than girls
• Majority of cases occur in the winter and
early spring
• Believed to be viral in etiology and is not
contagious
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Kawasaki Disease
• Diagnosis is based on clinical criteria by the
American Heart Association:
– fever for 5 or more days (102 – 104)
– a polymorphous exanthem
– nonpurulent conjunctivitis
– changes in the mucosa of the lips / oral cavity
– redness or edema with later desquamation of the
extremities
– at least one cervical lymph node > 1.5 cm in
diameter
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http://circ.ahajournals.org/cgi/content/full/110/17/2747
accessed 03-01-2010
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Kawasaki Disease
• Coronary artery aneurysms develop in
15% to 25% of untreated children
• May lead to ischemic heart disease or
sudden death
• Treatment
– IV immunoglobulin
– Aspirin
– Echocardiography and cardiac consult
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http://circ.ahajournals.org/cgi/content/full/110/17/2747
accessed 03-01-2010 357
Thank you for your time
and attention!
For further programming,
please visit us at:
www.4healtheducation.com
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