1 Facilitated by Partners In Healthcare and sponsored by Walgreens Evidence Based Pediatric...

1

Facilitated by Partners In Healthcare and sponsored by Walgreens

Evidence Based Pediatric Treatment Guidelines 2014:

Clinical Practice Strategies for the Retail Clinician

Wendy L. Wright, MS, RN, APRN, FNP, FAANPOwner – Wright & Associates Family Healthcare

Partner – Partners in Healthcare Education

Wright, 2014

Another Great Resource for Pediatrics

Wright, 2014 2

http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 05-01-2014

Development & Anticipatory Guidance

• Developmental Screening– 9 months– 18 months– 30 months

• Identify those infants and children with developmental disorders

3

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/3/645/F1 accessed 05-01-2014

Wright, 2014

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/3/645/F1

Development & Anticipatory Guidance

• Anticipatory Guidance–Every visit from birth – age 21

–Specific guidance is based upon age

4

http://brightfutures.aap.org accessed 05-01-2014

Wright, 2014

http://brightfutures.aap.org/

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

5Wright, 2014

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

Wright, 2014 6http://aapnews.aappublications.org/content/32/8/36.2.extract accessed 05-01-2013

http://aapnews.aappublications.org/content/32/8/36.2.extract

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 well-

child visits

Wright, 2014 7

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/2/436 accessed 05-01-2014

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

8Wright, 2014

http://www.guidelines.gov/content.aspx?id=12640&search=hearing accessed 05-01-2014

Dental Examination

• AAP recommendations– Begin at age 12 months– 18 months– 24 months– 30 months– 3 years of age– 6 years of age

9Wright, 2014

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

10Wright, 2014

http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011

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.

Wright, 2014 12

http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011

Lead Screening

• AAP recommendations– 12 months or…– 24 months

• Continued risk factor assessment throughout childhood

13Wright, 2014


Anemia Screening

• AAP recommendations– Age 12 months– Hemoglobin or hematocrit

• Continued risk assessment throughout childhood

14Wright, 2014


Wright, 2014

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.orgwww.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

Wright, 2014 16

http://care.diabetesjournals.org/content/36/Supplement_1/S11.full accessed 05-20-2014

http://care.diabetesjournals.org/content/36/Supplement_1/S11.full

General Health Counseling

• Seatbelts

• Helmets

• Sunscreen

• Smoke Detectors

• Pool Safety

• Carbon Monoxide

• Guns

• Domestic Violence17Wright, 2014

General Health Counseling

• Drugs

• Alcohol

• Smoking

18

Remember – School / sport physicals may be the only contact that the child has with a health

care professional in a yearWright, 2014

Immunization schedule: aged 0 through 18 years—United States, 2014

Wright, 2014 19

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

CDC. MMWR. 2005;54(RR-7):13.

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Wright, 2014

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.

Wright, 2014 21

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 age23Wright, 2014

HPV Vaccine

• Series of 3 injections– Day 0, day - 2 months and day - 6 months

• .5 ml injection IM injection into deltoid

24Wright, 2014

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)

Wright, 2014 25

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

Wright, 2014 26

Influenza

Wright, 2014 27

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)

Wright, 2014 29

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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http://www.who.int/influenza/vaccines/virus/en/

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

Wright, 2014 31http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/vaccine-recommendations-for-infants-and-children.html accessed 12-30-2012

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/vaccine-recommendations-for-infants-and-children.html

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/vaccine-recommendations-for-infants-and-children.html

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

32Wright, 2014

Worrisome Findings:Consider Hospitalization

• Altered LOC• Abnormal breathing• Tachycardia in presence of significant findings• Significantly elevated temperature• Petechiae• Cyanosis• Pallor• Delayed capillary refill (> 2 seconds)• Poor muscle tone

33Wright, 2014

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

34Wright, 2014

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

35Wright, 2014

Clinical Pearl:

Document visual acuity on all eye

complaints

36Wright, 2014

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

37Wright, 2014

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

38Wright, 2014

Hordeolum

39Wright, 2014

Internal Hordeola

40Wright, 2014

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– Often bilateral

41Wright, 2014

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

42Wright, 2014

Viral Conjunctivitis

43Wright, 2014

Bacterial Conjunctivitis

• Etiology– Staphylococcus aureus– Streptococcus pneumoniae/pyogenes– Haemophilus influenzae– Neisseria gonorrhea

• Symptoms– Redness, swelling, purulent discharge, itching– No symptoms until eye complaints began

44Wright, 2014

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

45Wright, 2014

Bacterial Conjunctivitis

46Wright, 2014

Conjunctivitis

• Bacterial– Non-palpable nodes

• GC and Chlamydia +

– Purulent discharge• GC-Mucopurulent

– Moderate conjunctival injection

– Unilateral at onset

• Viral– Palpable preauricular

node– Watery discharge– Mild-moderate

conjuctival injection– URI symptoms– Bilateral

47Wright, 2014

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

48Wright, 2014

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 short-term relief of vascular injection and redness• Common vasoconstrictors include naphazoline,

phenylephrine, oxymetazoline, and tetrahydrozoline

52Wright, 2014

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)

53Wright, 2014

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis

in Children and AdultsClinical Infectious Diseases Advance

Access published March 20, 2012

Wright, 2014 54

http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012

http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html

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: [email protected].

Wright, 2014 55

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

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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

http://www.medscape.com/viewprogram/5621

Wright, 2014 58

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



Wright, 2014 59

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



Antimicrobial Regimens in Children

Wright, 2014 60http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html 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.

Wright, 2014 61

http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html accessed 12-29-2012


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

Wright, 2014 62



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

Wright, 2014 63



When to Refer

Wright, 2014 64http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012


Ear Conditions

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Wright, 2014 66

Variations of Tympanic Membrane

Normal TMNormal TM

Acute OMAcute OM

Otitis Media Otitis Media with Effusionwith Effusion

67Wright, 2014

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

Wright, 2014 68

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.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013

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.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556



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)

Wright, 2014 69





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

Wright, 2014 70





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

Wright, 2014 71





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

Wright, 2014 72





Summary: AAP Updated Guidelines (cont.)

Wright, 2014 73


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




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

Wright, 2014 74





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

Wright, 2014 75





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

Wright, 2014 76





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 dayClindamycin (30 – 40 mg/kg/day) in three divided doses with or without concomitant

third generation cephalosporin

Ceftriaxone (50 mg IM or IV) for 3 days Clindamycin (30 – 40 mg/kg/day) in three divided doses with concomitant third

generation cephalosporinTympanocentesisConsult specialist

Wright, 2014 77





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

78Wright, 2014

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

79Wright, 2014





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

80

http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010Wright, 2014

http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412

OME

81Wright, 2014

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

82

http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010Wright, 2014

http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412

Otitis Externa

83Wright, 2014

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

84Wright, 2014

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

85Wright, 2014

Otitis Externa

• Signs–Erythematous, edematous canal

–Pain with tragal/pinna movement

–Yellow/green discharge

–Foreign body

–Pre or postauricular lymphadenopathy

86Wright, 2014

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

87Wright, 2014

Otitis Externa

• Plan– Therapeutic

• Warm compresses• NSAIDS/Tylenol• Prednisone• Auralgam• Wick

88Wright, 2014

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

89Wright, 2014

Pharyngitis

90Wright, 2014

Pharyngitis

• Epidemiology–Group A Beta Hemolytic Strep

• Most interest because of its association with severe complications

• Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis - complications

91Wright, 2014

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

92Wright, 2014

Exudative pharyngitis

Exudative pharyngitis

Differentials include:

Strep pharyngitis

Peritonsillar abscess

Mononucleosis

Viral pharyngitis

93Wright, 2014

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

94Wright, 2014

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

95Wright, 2014

Remember…Children with mono

have strep pharyngitis 50% of

the time

96Wright, 2014

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

97Wright, 2014

Peritonsillar Abscess

• Generally begins as an acute febrile URI or pharyngitis

• Condition suddenly worsens– Increased fever– Anorexia– Drooling– Dyspnea– Trismus

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• 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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• 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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Important Reminder

•If respiratory distress is severe,

do not examine the pharynx

103Wright, 2014

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

104Wright, 2014

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

105Wright, 2014

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

106Wright, 2014

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

107Wright, 2014

Asthma and Asthma

Exacerbation108Wright, 2014

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

109Wright, 2014

Asthma is...

• A disease of:– Inflammation

• Primary Process

– Hyperresponsiveness– Airway bronchoconstriction– Excessive mucous production

110Wright, 2014

AsthmaticAsthmaticNormalNormalJeffery P. In: Asthma, Academic Press 1998.

Epithelial Damage in Asthma

111Wright, 2014

Diagnosis of Asthma

112Wright, 2014

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.”

113

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.

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Diagnosis of Asthma

• History and Physical Examination

• Pulmonary Function Tests

• Monitoring:– Peak Flow Meters

114Wright, 2014

Symptoms and Signs of Asthma in Children

• Coughing, particularly at night• Wheezing• Chest tightness• SOB• Cold that lingers x months with a

persistent cough

115Wright, 2014

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.

116

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.

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Figure 17-1 Classifying Asthma Severity and Initiating Treatment in Children 0 to 4 Years of Age

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

Stepwise Approach for Managing Asthma in Children Age 0 to 4 Years

www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.

Step 1Step 1

Preferred:Preferred:

SABA

PRN

Step 3Step 3

Preferred: Preferred:

Medium-dose ICS

Step 5Step 5


High-dose ICS + either LABA

or Montelukast

Step 4Step 4


Medium-dose ICS + either

LABAor

Montelukast

IntermittentIntermittentAsthmaAsthma

Persistent Asthma: Daily MedicationPersistent Asthma: Daily Medication

Consult with asthma specialist if Step 3 care or higher is required. Consult with asthma specialist if Step 3 care or higher is required. Consider consultation at Step 2.Consider consultation at Step 2.

Patient Education and Environmental Control at Each Step

Step Up iStep Up if NeededNeeded

((first check first check adherence, adherence,

inhaler inhaler technique, & technique, &

environmental environmental control)control)

Step Down iStep Down if PossiblePossible

(& asthma is (& asthma is well controlled well controlled

at least 3 at least 3 months)months)

Assess Assess ControlControl

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

Step 2Step 2Preferred:Preferred:Low-dose

ICS Alternative: Cromolyn

or Montelukast

Step 6Step 6Preferred:Preferred:

High-doseICS + either

LABA or Montelukast

and Oral Systemic

Corticosteroids

Classifying Asthma Severity and Initiating Treatment in Children 5 to 11 Years of Age

Stepwise Approach for Managing Asthmain Children Age 5 to 11 Years

www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.

Assess Assess ControlControl

Stepwise Approach for Managing Asthma in Patients Aged≥12 Years

www.nhlbi.nih.gov/guidelines/asthma/asthgdlnWright, 2014 121

Major Focus in EPR-3

• Controlling asthma is a major focus of the EPR-3 guidelines

122Wright, 2014

Assessing Asthma Control (Youths 12 Years of Age and Adults)Follow-up Visits: Determine Level of Control and Treatment NeededComponents of Control Well-controlled

Not Well-controlled

Very Poorly Controlled

Impairment

Symptoms≤2 days/week >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 beta2-agonist 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

Validated QuestionnairesATAQACQACT

0≤0.75*≥20

1-2≥1.516-19

3-4N/A≤15

Exacerbations0-1/year ≥2/year (see note)Consider severity and interval since last exacerbation

Risk

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 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.

123Wright, 2014

Monitoring Control in Clinical Practice: Asthma Control Test™ for Patients Aged ≥12 Years1

1. Asthma Control Test™ copyright, QualityMetric Incorporated 2002, 2004. All rights reserved.2. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/epr3/resource.pdf. Accessed February 5, 2007.

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

124Wright, 2014

Acute Asthma Exacerbation Management

125Wright, 2014

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 hospitalization126Wright, 2014

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

127Wright, 2014

Acute Asthma Exacerbation

• Measure Spirometry vs. Peak Flow• FEV1 is most important number

– >80% predicted– 50% – 79% of predicted– < 50% of predicted

128Wright, 2014

Spirometry Results

• FEV1 = 62% of predicted

• FEV1/FVC = 90%

• What does this mean for our patient?

129Wright, 2014

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

130Wright, 2014

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

131Wright, 2014

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

132Wright, 2014

Patient Education

• Have plan in place for next URI

• Preventative therapy?

• Environmental modification

• Daily peak flows

133Wright, 2014

Severity of Acute Exacerbations

Wright, 2014 134http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf accessed 05-01-2014

http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

Bronchiolitis

135Wright, 2014

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

spring136Wright, 2014

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

137Wright, 2014

Burden of Illness

• Typically, bronchiolitis is a mild illness

• Risk factors for more severe illness include:– Prematurity

– Heart or lung disease

– Weakened immune system

138Wright, 2014

Complications of Bronchiolitis

• Hospitalization

• Respiratory distress

• Children with this condition are more likely to develop asthma later in life

139Wright, 2014

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

140Wright, 2014

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

141Wright, 2014

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

142Wright, 2014

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 helpful143Wright, 2014

Pharmacotherapy

• Corticosteroids

• Inhaled corticosterioids

144Wright, 2014

Bronchitis

145Wright, 2014

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)

146Wright, 2014

Treatment for Bronchitis

• Symptomatic

• Increase fluids

• Steam

• Guiafenesin or similar

• First generation antihistamine

• Cough syrup – usually not helpful or effective

147Wright, 2014

Bronchitis

• Treatment–Antibiotics rarely needed

• If needed, atypical pathogen coverage

–Prednisone• Short, non-tapering burst is often very

effective

• i.e. 5 days

148Wright, 2014

Pertussis

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150

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.

Pertussis: Highly Communicable,Frequently Overlooked

• Acute respiratory tract infection causedby 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 RE, Jenson HB, Stanton BF, eds, Nelson Textbook of Pediatrics. 18th edition. Philadelphia, PA: Saunders Elsevier;2007:1178-1182. 4. Cherry JD. Pediatrics. 2005;115(5):1422-1427.

Eye of S

cience /Photo R

esearchers, Inc.

151Wright, 2014

Reported Cases of Pertussis Are Highestin Adolescents and Adults …

• ~10,000-25,000 cases of pertussisare reported in the US every year1

• ~60% of reported cases occuramong adolescents and adults2

• Reported cases are the tip ofthe iceberg

– Estimated actual cases amongadolescents and adults:800,000-3.3 million per year3

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); MKT18596 (2007); MKT 18761 (2008). 3. Cherry JD. Pediatrics. 2005;115(5):1422-1427. 4. CDC. MMWR. 2005;55(RR-14):1-16.

“Despite increasing awareness and recognition of pertussis as a diseasethat affects adolescents and adults, pertussis is overlooked in thedifferential diagnosis of cough illness in this population.”4

Courtesy of the Centers for Disease Control and Prevention (CDC).

152Wright, 2014

The Very Young are Very Vulnerable to Complications of Pertussis

AgeNo. 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

References: 1. CDC. MMWR. 2002;51(4):73-76. 2. CDC. MMWR. 2005;54(RR-14):1-16.

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

Pertussis complications, hospitalizations, and deaths1

153Wright, 2014

• Multicenter study in France, Germany, Canada, US

• Study population: 95 infants ≤6 months of age with lab-confirmed pertussis

• Household members were responsible for 76%-83% of transmission to infants in 44 cases where a source could be identified

Reference: 1. Wendelboe AM, et al. Pediatr Infect Dis J. 2007;26(4):293-299.

Part-timecaretaker2% Grandparent

6%

Friend/Cousin10%

Father18%

Sibling16%

Aunt/Uncle10%

Transmitting Pertussis to InfantsIs a Family Matter1

Mother37%

“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.”

154Wright, 2014

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 agea ACIP = Advisory Committee on Immunization Practices. b Tdap = Tetanus, diphtheria, and acellular pertussis vaccine.

Reference: 1. CDC. MMWR. 2006;55(RR-17):1-37. 2. CDC. MMWR. 2006;55(RR-3):1-43. 155Wright, 2014

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 children not immunized

156Wright, 2014

The ACIP Recommends:Build a Cocoon of Protection Around Infants1

• Tdap is recommended for all adultswho have or anticipate havingclose 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.

157Wright, 2014

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. 158Wright, 2014

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

Wright, 2014 159

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm accessed 05-01-2013

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm

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

Wright, 2014 160

Diagnostic Tests for Pertussis

NP culture on special media (Regan-Lowe, Bordet-Gengou)

PCR Serologic tests Increased WBC

with an absolute lymphocytosis

DFA—variable sensitivity/specificity

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161Wright, 2014

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 2-5.

162Wright, 2014

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 effectiveReferences:1. Edwards KM, et al. In: Plotkin SA, et al, eds. Vaccines. 1999:293-344. 2. CDC. The Pink Book, 7th ed. 2002:75-88. Available at: www.cdc.gov/nip/publications/pink/pert.pdf. Accessed March 15, 2005. 163Wright, 2014

http://www.cdc.gov/nip/publications/pink/pert.pdf

Websites with Vaccine Information

• www.pertussis.com• www.cdc.gov/nip/vacsafe• www.cispimmunize.org• www.vaccine.chop.edu• www.vaccineprotection.com

164Wright, 2014

Stridor

165Wright, 2014

Stridor

• Few conditions in pediatrics are as emergent and potentially life threatening as an upper airway obstruction

• Rapid identification and treatment is essential

166Wright, 2014

Differential Diagnosis for Stridor

• Differential– Laryngotracheobronchitis (croup)– Mechanical obstruction (birth)– Foreign body aspiration– Peritonsillar abscess– Epiglottitis– Angioedema

167Wright, 2014

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

168Wright, 2014

Croup

Subglottic narrowing169Wright, 2014

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 fever

170Wright, 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

171Wright, 2014

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

172Wright, 2014

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 helpful173Wright, 2014

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

174Wright, 2014

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

175Wright, 2014

Pneumonia

• Children > 5 years – Mycoplasma, S. pneumoniae, Chlamydia

pneumoniae

• Physical Examination– Vital signs– Respiratory distress– Auscultate lungs (egophony, bronchophony)– Palpate for tactile fremitus

176Wright, 2014

Pneumonia

• Diagnostic– Chest Xray is recommended for all

suspected cases of pneumonia

177Wright, 2014

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

Wright, 2014 178http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed 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

Wright, 2014 179http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed 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

180Wright, 2014

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!!

181Wright, 2014

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

182Wright, 2014

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?

183Wright, 2014

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 examination184Wright, 2014

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 history185Wright, 2014

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

186Wright, 2014

GI/GU

187Wright, 2014

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

188Wright, 2014

Causes of Chronic or Recurrent Pain

• Constipation

• Musculoskeletal pain

• Lactose intolerance vs. celiac disease

• Colitis vs. Crohn’s

• IBS

189Wright, 2014

190

Diarrhea

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191

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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192

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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193

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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194

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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195

Symptoms• Sudden onset• Frequent bowel movements• Loose, watery stools• Bloody stools• Abdominal cramping• Thirst• Decreased urination• Dizziness• Fatigue

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196


• 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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197

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 diarrheaWright, 2014

198

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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199

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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200

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

202Wright, 2014

Constipation

• Options for treatment–Fiber intake

–Polyethylene glycol (Miralax)

–Lactulose

–Milk of Magnesia

–Behavioral modification

203Wright, 2014

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?204Wright, 2014

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– Midwest-highest incidence 205Wright, 2014

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

206Wright, 2014

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,

coughing207Wright, 2014

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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• 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

209Wright, 2014


• Rigidity– Important predictor of appendicitis

– Involuntary spasm of the abdominal musculature

– Caused by peritoneal inflammation

• Markle’s sign– Heel-drop jarring test

210Wright, 2014

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 211Wright, 2014


• 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

212Wright, 2014

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

213Wright, 2014

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

214Wright, 2014

http://www.sciencedaily.com/releases/2013/12/131202171811.htm accessed 05-01-2014

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

215Wright, 2014

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 – 10 days

216Wright, 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

217Wright, 2014

Enuresis

• Treatment Options– Desmopressin (DDAVP )(Nasal spray no

longer approved for this indication)– Tricyclic antidepressants (caution advised)– Bed wetting alarm– Bladder training– Constipation treatments

218Wright, 2014

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

219Wright, 2014

Millions of Young Athletes

• Millions of young athletes are involved in a variety of activities

220Wright, 2014

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

221Wright, 2014

Kids Just Want to Have Some Fun!!

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223

Frequency

• AAP recommends examinations every 2 years

• Many schools have different recommendations

http://www.emedicine.com/sports/TOPIC156.HTM#section~TimingFrequencyandTypesofEvaluations accessed 02-10-2010 Wright, 2014

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

224

http://pedsinreview.aappublications.org/cgi/content/extract/22/6/199 accessed 02-10-2010

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225Wright, 2014

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

226

Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY, NY: The McGraw-Hill Companies.Wright, 2014

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

227

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

228Wright, 2014

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

229Wright, 2014

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 needed230Wright, 2014

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

231Wright, 2014

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

233Wright, 2014

Headache• Indications for Headache Work-up

–Systemic symptoms–Neurologic signs and symptoms–Onset–Older (< 5 or > 50)–Previous headache

Dodick DW. Adv Stud Med. 2003;3:87-92.

234Wright, 2014

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

235Wright, 2014

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

236http://www.aafp.org/afp/20050601/tips/13.html accessed 08-22-2008Wright, 2014

Syncope

237http://www.aafp.org/afp/20050601/tips/13.html accessed 08-22-2008Wright, 2014

Concussion Guidelines

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http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013

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)

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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

240Wright, 2014

http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013

241

Concussion

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http://knowconcussion.org/wp-content/uploads/2011/06/graded_symptom_checklist.pdf accessed 05-19-2013

Administer prior to season; administer immediately after injury.Return to play when symptoms are consistent with baseline score

Return to Play

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http://bjsm.bmj.com/content/47/5/259.full.pdf accessed 05-18-2013

This tool is not used alone but provides guidance for return to playShould NOT be returned to play on day of concussion

Dermatologic Conditions

243Wright, 2014

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

244Wright, 2014

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

245Wright, 2014

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

246Wright, 2014

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

247Wright, 2014

Verruca Vulgaris

248Wright, 2014

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)

249Wright, 2014

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)

250Wright, 2014

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

251Wright, 2014

Urticaria

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Urticaria

• Plan–Therapeutic

• Stop medications if possible

• Stop suspected foods or drinks

• Cool compresses

• Antihistamines/H2RA

• Prednisone

253Wright, 2014

Urticaria

• Plan–Educational

• Avoid causes

• Educate regarding possible etiology

• Discuss side effects of antihistamines (sedation)

254Wright, 2014

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 months

255Wright, 2014

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 yellow-brown

– Initially, looks like an inner tube

– Crust appears and if removed, is bright red and inflamed

256Wright, 2014

Impetigo

257Wright, 2014

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

258Wright, 2014

Impetigo

• Educational–Good handwashing and hygiene

–No school/daycare for 24 - 48 hours

–Wash sheets and pillowcases

–Monitor for serious sequelae

259Wright, 2014

Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of

Methicillin –Resistant Staphylococcus aureus Staphylococcus aureus

Infections in Adults and Children: Executive Summary

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Liu, Catherine et. al. MRSA Treatment Guidelines CID 2011:52 (1 February) 285-292

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 CA-MRSA in your community (generally thought of as < 10 – 15%)

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Guilbeau, J.R. and Fordham, P.N. Evidence-Based management and Treatment of Outpatient Community-Associated MRSA. The Journal for Nurse Practitioners. 2010; Vol 6(2):140-145

264

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)

Wright, 2014 265

Rifampin

• No longer recommended as a single agent or for adjunctive therapy for the treatment of skin and soft tissue infections

Wright, 2014 266

Children

• Simple, uncomplicated impetigo:– Mupirocin 2% topical ointment

• Avoid TCN or similar in children < 8 years of age

Wright, 2014 267

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 resistanceWright, 2014 268

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 5-14 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

270Wright, 2014

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

271Wright, 2014

This is NOT a Lyme Bearing Tick

272Wright, 2014

Lyme Bearing Tick

273Wright, 2014

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 274Wright, 2014

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

275Wright, 2014

Summer 2009

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Erythema Migrans

277Wright, 2014

Erythema Migrans

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• Signs– Systemic symptoms: Stage 3

• Facial palsy• Meningitis• Carditis

• Diagnosis– R/O Ringworm (Tinea Corporis)

279Wright, 2014


• 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

280Wright, 2014

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

281Wright, 2014

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

282Wright, 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

283Wright, 2014

Pityriasis Rosea

284Wright, 2014

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

285Wright, 2014

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

286Wright, 2014

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

287Wright, 2014

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

288Wright, 2014

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

289Wright, 2014

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 abuse290Wright, 2014


291Wright, 2014

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• TCA 292Wright, 2014



• May resolve on own in 6 - 9 months• Contagious until lesions are gone• Benign• Recurrence very common

293Wright, 2014

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 claw-shaped suckers

294Wright, 2014

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 itching295Wright, 2014

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

296Wright, 2014

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

297Wright, 2014

Scabies

298Wright, 2014

Scabies

•

299Wright, 2014

Scabies

• Diagnosis–Scraping to look for mite, eggs or

feces

• Plan–Diagnostic: Scraping–Therapeutic

• Permethrin 5% cream

300Wright, 2014

Scabies• Plan

– 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

301Wright, 2014

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 weeks302Wright, 2014

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

303Wright, 2014

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 furniture304Wright, 2014

Prescription Lice ProductsBenzyl

alcohol, 5% (Ulesfia)1

Malathion, 0.5%(Ovide)2

Spinosad, 0.9%

(Natroba)3

Ivermectin, 0.5%

(Sklice Lotion)4

Lindane, 1%5

Age indication

≥6 mo Safety not shown <6 y

≥4 y ≥6 mo Use w/caution in those <110

lb

Dosage 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

Time of application

10 min; repeat

treatmentafter 7 d

8–12 hrs; repeattreatment 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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Keeping Kids in School

• The AAP and National Association of School Nurses state: No healthy child should be allowed to miss school timebecause 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 evidence-based 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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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

307Wright, 2014

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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309

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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310

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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313

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 corticosteroidsWright, 2014

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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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Acne Vulgaris• Diagnosis

– 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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• 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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• 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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• Plan– Diagnosis: None– Therapeutic: Symptomatic Treatment

• NO ASPIRIN• Clip Nails• Caladryl or Benadryl• Antiviral

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• 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– Pink– Scaly– Round– May be 3 – 5 cm in

size

• Treatment– Antifungal – topical

• Miconazole• Clotrimazole

– Avoid touching as it is very contagious

– No contact sports x 48 hours into treatment

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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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• Symptoms

–Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling

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• 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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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 334Wright, 2014

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

336http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010Wright, 2014

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


Roseola

• Treatment–Ibuprofen

–Acetaminophen

–Tepid baths• Cautiously with

fever


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 are

immunocompromised

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• 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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• 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 feet341Wright, 2014

• Fifth’s Disease

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Fifth’s Disease

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• 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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• 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

Wright, 2014 348http://wwwnc.cdc.gov/eid/article/18/2/11-1147-f1.htm accessed 05-01-2013


• 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 349Wright, 2014


• 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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• Plan–Diagnostic: None–Therapeutic

• Tylenol• Warm baths• Oragel or diphenhydramine/Maalox• Magic mouthwash

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• 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

contagious355

http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2014

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

diameter356

http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2014

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

357http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2014

358

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