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The Most Frequent Issues for School Nurses of Tots

By Jane A Chevako, MD

August 18, 2017

and Trots:Hots, SnotsJane Chevako MD

I disclose the absence of personal financial relationships with commercial interests relevant to this educational

activity within the past 12 months.

Visits to Pediatric Providers1. Well Child Care2. Acute URI (common cold)3. Otitis Media (ear infections)4. Acute Pharyngitis (sore throat)5. Attention Deficit Disorder6. Asthma7. Sinusitis8. Immunizations9. Streptococcal Pharyngitis10. Allergic Rhinitis (allergies)

Adapted from www.pediatricsnow.com/2008/01/top-10-pediatric-visits-for-2007/

Temperature

• NORMAL core body temperature: 37° C (98.6° F)

• Body temperatures have a circadian rhythm, being lowest in early morning, and can vary by 1° C throughout the day.

• Vary by type of thermometer.

• Vary by location taken.

Don’t add or subtract.

Where did you take it and what number did you get?

HOTS: Definition of a FEVER

“Fever is an elevation of body temperature mediated by an increase of the

hypothalamic regulatory set-point…

Fever is one manifestation of the inflammatory response produced by

cytokine-mediated host defense mechanisms.”

1. Nelson’s Textbook of Pediatrics

Fever Phobia

• When do you get nervous?

• Appearance vs. Temperature.

• Goal is overall comfort of the child.

• Watch for worrisome signs and symptoms.

Sullivan, J, et.al. Fever and Antipyretic Use .in Children, Pediatrics. 2011 Mar;127(3):580-7. doi: 10.1542/peds.2010-3852. Epub 2011 Feb 28

Crocetti, M, et.al. Fever Phobia Revisited: have parental misconceptions about fever changed in 20 years. Pediatrics. 2001;107(6):1241-1246.

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Acetaminophen:

• Safe at recommended doses.

• Narrow margin of safety: • The smallest margin between the ‘safe’ dose and

the ‘serious harm’ (or ‘fatal’) dose of all OTC drugs.

2. https://www.propublica.org/article/tylenol-mcneil-fda-kids-dose-of-confusion

3. https://www.propublica.org/article/new-court-docs-maker-of-tylenol-had-a-plan-to-block-tougher-regulations

1. J. Sullivan, et.al., Fever and Antipyretic Use in Children, Pediatrics. 2011 Mar;127(3):580-7. doi: 10.1542/peds.2010-3852. Epub 2011 Feb 28

Acetaminophen:

• Found in LOTS of products:

• 28,000,000,000 doses sold.

• Found in over 600 common OTC products.

• Overdose is common when taking more than one product containing the drug.

• Most common medical overdose in children, with over 80% from unsupervised ingestions.

Acetaminophen: Harms

• Leading cause of liver failure in US.

• >100,000 calls to poison centers.

• ~600,000 ER visits with 100,000 being kids!

• ~400 deaths and can be fatal to an unborn fetus.

• Lawsuits consolidated into a multidistrict litigation.

2. https://nybc.wordpress.com/2009/07/12/28-billion-doses-of-acetaminophen-per-year-sold-in-the-us-liver-damage-caused-acetaminophen-leads-to-40-deaths-and-42000-hospitalizations-why-not-recommend-mac-n-acetylcycsteine-as-antido/

1. http://www.drugwatch.com/tylenol/ and drugwatch.com/2014/01/28/fda-limits-acetaminophen-liver-damage/

3. https://healthland.time.com/2009/08/14/70000-u-s-kis-overdose-each-year-&E2%80%94-accidentally-%E2%80%94-on-everyday-household-meds/

Ibuprofen: Benefits

• Antipyretic: works better on higher fevers.

• Lasts for 6-8 hours

• Larger margin of safety.

• Analgesic.

• Anti-inflammatory.

Ibuprofen

• Comes in 2 DIFFERENT STRENGTHS

• Children’s Liquid = 100 mg per 5 mL

• Infant Concentrated Drops = 50 mg per 1.25 mL

= 200 mg per 5 mL

• Ibuprofen Infant drops are 2 times more concentrated than children’s liquid!

• This is counterintuitive …CRAZY DANGEROUS

Fever can be Beneficial

• It is not a primary illness.

• Has a short duration, benign and helpful.

• Reduce the bacteria and viruses.

Retards germ growth and reproduction.

• Trigger production of neutrophils.

• Enhance T-lymphocyte proliferation.

• Aids the acute-phase reaction.

Sullivan, J, et.al. Fever and Antipyretic Use in Children, Pediatrics. 2011 Mar;127(3):580-7. doi: 10.1542/peds.2010-3852. Epub 2011 Feb 28.

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Fever: When To Worry• Child looks sick.

• Unable to drink or dehydrated.

• Focal signs.

• Neck stiffness.

• Immunocompromised.

• Implant (examples: VP-shunt, cardiac).

• History of Febrile Seizure.

• Infants less than 56 days (8 weeks).

For a child with a FEVER:

STOP (Exclude from School)HOME: UNTIL NO FEVER FOR 24°

STUDENTS WHO NEED EXTRA CAUTION

INCLUDE THOSE WHO ARE

IMMUNOCOMPROMISED, HAVE IMPLANTS,

HAVE NECK STIFFNESS, ARE NONVERBAL

OR HAVE A HISTORY OF FEBRILE SEIZURES.

CAUTION

GO

Viral Upper Respiratory Infection

Viral URI: The Common Cold

• The most common infectious condition of children!

• Expect about 12-15 in the 1st year of life.

• Then, about 6-10 per year.

• Most contagious the first few days.

• Last 5-7 days and are usually improving by the 10th day.

Interconnections

SINUSES

Conjunctivitis

Sinusitis

Otitis

TonsillitisPharyngitis

Pneumonia

Asthma

Gastroenteritis

(Breathe)LUNGS

GI TRACT (Swallow)

EYES

EARS

NOSE

THROAT

GERMS

FLOW of SECRETIONS

Symptoms of Upper Respiratory Infections

• Fever

• Aches, pains, fussiness

• Rhinorrhea (runny nose )

• Congestion (stuffy nose)

• Cough

• Ear pain

• Sore throat

• Decreased appetite

Treating: Viral URI Symptoms

• Hydration: Fluids and rest. NO ANTIBIOTICS!

• Fever: Treat the discomfort. NO ASPIRIN!

• Congestion: Saline, suction or flush, and humidification.

• Cough: Try honey, if >1 year of age.

• Scratchy throat: Soothing foods, lozenges.

• Tincture of time.

1. http://www.webmd.com/cold-and-flu/features/cold-cough-home-remedies-children

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What About Cough and Cold Medicines?

• Cough suppressant: Reduce Cough

• Decongestants: Stuffy Nose

• Antihistamines: Runny Nose

• Expectorant: Loosen Mucous

Coughs

• Cough is reflex response.

• Physiologic function.

• Clears secretions, obstructions and irritants.

• Warns that something bad is in the air.

• Important: treat underlying condition.

1. pediatrics.aappublications.org/content/99/6/918.full?sid=7bc457a-5354-4620-932-e20465562b95

Coughs

• Suppressing cough may be bad.

• Pooled secretions.

• Obstructed airway.

• Secondary infection (pneumonia).

• Hypoxemia.

1. pediatrics.aappublications.org/content/99/6/918.full?sid=7bc457a-5354-4620-932-e20465562b95

Cough Suppressants

Antitussive agents:

• Work centrally in brain by elevating the threshold for cough.

• Effective for chronic, non-productive coughs.

• Can trigger histamine release:

Not safe in atopic children.

Cough Suppressants

• Efficacy: NOT more effective than placebo.

• Significant adverse events, including death.

• Example:

• Codeine (Rx-narcotic)

• Dextromethorphan [OTC]

• Abused by 1 in 10 teenagers.

• Euphoric and dissociative hallucinations.

Decongestants: Stuffy Nose

• Vasoconstrictors.

• Temporarily relieve nasal congestion.

• May promote nasal and sinus drainage.

• Can cause serious and fatal adverse effects.

• Example:

• Phenylephrine

• Pseudoephedrine and Ephedrine

• Phenylpropanolamine

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Illicit Production of METHAMPHETAMINE:From Pseudoephedrine, Ephedrine and

Phenylpropanolamine

Combat Methamphetamine Epidemic Act 2005

became part of the Patriot Act:

• Sold behind the counter.

• Limits amount that can be purchased.

• Must show photo identification.

• Purchaser information kept for 2 years.

Antihistamines: Runny Nose

Histamine H1-receptor antagonists:

• Inhibit the release of histamine from mast cells, basophils and eosinophils.

• Anti-Allergy.

• Anti-Inflammatory.

• Anti-Pruritic.

Great for itching of atopic dermatitis.

Antihistamines: Multi-Generational

First Generation Antihistamines

Second Generation Antihistamines

Brompheniramine

Chlorpheniramine

Diphenhydramine

Doxylamine

Hydroxyzine

Meclizine

Promethazine

30+ more

Cetirizine

Fexofenadine

Loratadine

Antihistamines: Are They Safe?

• Second generation are better and safer.

• Well tolerated.

• Very helpful for allergies and atopic dermatitis.

• Cause less sedation, helps school performance.

• Have been used extensively in toddlers.

• Can be abused for hallucinogenic effects.

2. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm051137.htm1. http://www.medscape.com/viewarticle/410914_3

Expectorants: Mucous

• Expectorants increase the volume and reduce the viscosity of secretions.

• Lubricate an irritated respiratory tract.

• Thin mucous.

• Cilia bring up loosened secretions from lungs.

• May have more efficient cough.

• Example:

• Guaifenesin1. http://www.medicinemet.com/script/main/art.asp?article key=24354 +

Expectorants: Are They Safe?• Limited data to show efficacy.

• Risk of overdose.

• Toxicity (and death) in < 2 years of age.

• Not recommended < 4 years of age.

• Guaifenesin with dextromethorphan

Counterintuitive:

Why looser secretions to cough them out and then suppress the cough?

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Are Cough and Cold Medicines Safe?

PROVEN TO BE NOT EFFECTIVE.

CONTRAINDICATED under 2 years of age!

• Limited effectiveness with high risks of toxicity.

• Significant adverse events and DEATHS.

• No established dosing recommendations.

• Potential for abuse.

NOT RECOMMENDED 2-5 years of age.

3. MMWR Mob Mortal Wkly Rep. 2007 Jan 12;56(1):1-4. Centers for Disease Control and Prevention (CDC)

1. http://www.fda.gov/forconsumers/consumersupdates/ucm048682.htm2. http://www.webmd.com/cold-and-flu/features/cold-cough-home-remedies-children

CHANGE CONTRAINDICATION: TO 4 years of age

Who NOSE?

• Olfaction: smell.

• Warms and humidifies air.

• Hairs trap the large particles.

• Ciliated cells and mucous layer trap smaller particles.

Sinuses:

• Complicated cavities in our heads.

• Filled with air.

• Decrease weight of head.

• Help with phonation.

Sinuses:

• Ciliated cells and mucous layer trap smaller particles.

• Part of our immune response.

(Lysozymes, Secretory IgA)

• Ostia: TINY openings that connect sinuses to the nose.

• Air spaces have no direct blood flow.

Anatomy of Sinuses:Symptoms of aSinus Infection

• Bugger color does not indicate infection.

• Persistent respiratory symptoms after 10 days without improvement.

• +/- Fever.

• +/- Facial pain.

• +/- Headache.

• +/- Drainage.

• “My face is going to fall off” test.

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Treating Sinusitis:Green buggers do NOT always need treatment.

• Consider Wait and Watch: If symptoms are mild, less than 10 days and there is no fever. Push fluids.

• Nasal Irrigation and Flushing: May be helpful especially for thick secretions. In health room?

• Decongestants, antihistamines and intranasal steroids: Have not been proven to be helpful.

• Imaging: Routine images not recommended. A CT scan is only for complications or failure to cure.

Judicious Antibiotic StrategiesFor Acute Sinusitis

1. Persistent = Not improving by 10 days:• Nasal drainage of any quality.

• Daytime cough.

2. Worsening = After URI has improved:• Worsening fever or new onset.

• Nasal discharge.

• Daytime cough.

3. Severe = At least 3 days of:• Persistent fever (≥39°C).

• Purulent nasal discharge.

Nasal Foreign Body (FB)

Be suspicious when there is:

Smelly breath or bad halitosis.

Purulent drainage from one nostril.

A history that “something” went up there.

For student with URI

OR RUNNY NOSE:

STOP (Exclude from School)

GO (Back to Class)

HOME: FEVER, LOOK SICK, BAD SNOT,

HEADACHE, SEVERE PRESSURE…

CLASS: IF POSSIBLEGO

CAUTION

BE SUSPICIOUS FOR A FOREIGN BODY

BE SUSPICIOUS FOR A FB IF ONLY ONE

NOSTRIL IS RUNNING!

Oh, Why Do You Think My Eyes Are Pink?

• Infectious conjunctivitis

Viral

Fungal

Lice

Bacterial

• Allergic conjunctivitis

• Irritant conjunctivitis

• Chemical conjunctivitis

Acute Conjuntivitis

Allergic Conjuntivitis

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Treating Bacterial Conjunctivitis

• Wait for it to go away: 5-7 days.

• Treat symptoms.

• Breast milk.

• Antibiotic Eye Drops.

For a child with RED EYES:

STOP (Exclude from School)

GO (Back to Class)

HOME: TRAUMA, FOREIGN BODY, HERPES,

IF PURULENT FLUID: UNTIL TREATED

CLASS: IF CLEAR OR NO DRAINAGE.

REDNESS DOES NOT HAVE TO BE GONE!

GO

CAUTION

Watch for signs of orbital or periorbitalcellulitis!

CALL 911

For a child with PERIORBITAL CELLULITIS:

Oh, Dear I Fear It Is My Ear

Anatomy of the Ear

MIDDLE EAR INFECTIONS: Acute Otitis Media (AOM)

• The most common reason antibiotics are prescribed for children.

• Common reason for pediatric visit.

• Cannot be determined be symptoms alone!

• Eustachian tube (angle and length).

• Requires unobstructed otoscopic exam.

1. peditrics.aappublications.org/content/125/5/e1154 Symptoms or Symptom-Based Scores Cannot Predict Acute Otitis Media at Otitis-Prone Age

2.pediatrics.aappublications.org/content/early/013/02/20.2012-3488 The Diagnosis and Management of Acute Otitis Media

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Acute Otitis Media (AOM):

Acute Otitis Media needs to meet all 3 criteria:

1. Rapid onset of symptoms.

• Pain, irritability, crying, pulling ears.

• +/- Fever.

• Rupture.

• May have no symptoms.

2. Fluid in the middle ear.

3. Signs of middle ear inflammation.

Pink or Red?

• Inflammation:

• Bright red tympanic membrane (TM), individual swollen blood vessels can be seen.

• Edema of the TM makes it cloudy or opacified.

• TM is no longer translucent.

• Crying can make the TM pink, but this goes away as child calms down.

The Normal Ear

• Grey or pink

• Shiny

• Translucent

• Good light reflex

Otitis Media with Effusion (OME)

• Grey to pink

• Clear fluid (effusion)

• Bubbles (air + fluid)

• No inflammation

• Not bulging

AOM: Fluid in the middle ear with inflammation

• Middle Ear Fluid

• Fullness or bulging

• Opacified or cloudy

• Not Mobile

• Ottorhea

• Inflammation of the TM

pediatrics.aappublications.org/content/early/013/02/20.2012-3488

Bullous OM:Blisters on the

Ear Drum

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No Antibiotics For:

• Normal Ear

• Otitis Media with Effusion

• Acute Otitis Media(With minimal signs and symptoms)

Treating AOM: Pain

Treat pain: • Treat the pain.

• Ibuprofen may be more effective:

Helps with inflammation.

• Antipyrine/benzocaine may help pain:

There is little concern for ear drum rupture.

No bullous lesions

Treating AOM: Wait and Watch

• Don’t start antibiotics right away.

• 75% of acute ear infections go away on their own.

• Pain: control with analgesics.

Treating AOM: Antibiotics

Benefits of antibiotics:

• 90% go away. (Additional 15%)

• Improvement of symptoms:

Pain may go away in 1 day rather than 2 days.

• Amoxicillin is still the first-line therapy.

• Does not prevent mastitis.

Judicious Antibiotic StrategiesFor Acute Otitis Media

• Severe illness.

• Severe ear pain or pain lasting > 48 hours.

• Temperature ≥ 39◦.

• Laterality: Bilateral.

• Patient age: < 6 months need treatment.≤ 23 months likely benefit.

• Ottorhea: Ruptured TM or patent tube.pediatrics.aappublications.org/content/132/6/1146 Principles of Judicious Antibiotic Prescribing for Upper Respiratory Infections in Pediatrics.

For a child with EAR PAIN:

GO (Back to Class)CLASS: IF PAIN CAN BE CONTROLLEDGO

CAUTION

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Dr. Jane, My Throat Hurts.

• Sore throat is a common complaint.

• Why have tonsils?

• Out of 100 patients with a sore throat:

85 will have a virus.

15 will have Group A β-hemolytic Streptococcus.

85 OF 100 (85%)VIRAL PHARYNGITIS

Gradual onset of illness

Early fever

Anorexia

Moderate throat pain

Small cervical nodes

May have cough, runnynose, conjunctivitis

PHARYNGITIS: Comparing Symptoms

15 OF 100 (15%)STREP PHARYNGITIS

Can have sudden onset

Fever can be high (40°), can last for 1-4 days

Difficulty swallowing

Early sore throat, may be severe

May have large nodes, often tender nodes

Usually no cough, runny nose, conjunctivitis

“I have strep again.”

Symptoms of Strep Throat

Strep can present with:

Headache

Neck pain

Backache

Stomachache

Vomiting

Fever

Rash

Trouble swallowing and/or

A sore throat.

PHARYNGITIS: On Exam

85 OF 100 VIRAL

PHARYNGITIS

Pharynx: not so bad

Tonsils: small exudates

Hoarse voice

15 OF 100STREP

PHARYNGITIS

1/3 of Patients5 OF 15

Big, red, tonsilsPetechiae on palate

Large exudates, pus

Mash potato voice

2/3 of Patients10 OF 15

Small tonsils

No exudates

Normal voice

Who To Send for a STREP TEST?

Test if ≥2 of these symptoms:

• Fever or history of fever.

• Tonsillar exudates or swelling.

• Swollen and tender cervical lymph nodes.

• Absence of cough.

• Less than 15 years of age.

1. pediatrics.aappublications.org/content/132/6/1146 Principles of Judicious Antibiotic Prescribing for Upper Respiratory Infections in Pediatrics.

(History of strep pharyngitis)

Test for Streptococcal Pharyngitis

• Requires confirmation:

• Rapid-antigen strep testing.

• NAAT (Nucleic Acid Amplification Test).

• Culture.

pediatrics.aappublications.org/content/132/6/1146 Principles of Judicious Antibiotic Prescribing for Upper Respiratory Infections in Pediatrics.

• Rapid-Strep test does NOT differentiate:

active disease vs. asymptomatic carriers.

• Colonization rates may be 15-20%.+

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Treating Strep: Antibiotics

Benefits of antibiotics:

• MAY shorten fever, sore throat, headache.

• Reduces horizontal transmission.

Prevents secondary cases.

• Preventing suppurative complications:

• Peritonsillar abscess.

• Acute otitis media.

• Acute sinusitis.

• Recurrent strep when treatment is too rapid?

85%VIRAL PHARYNGITIS

15%STREP PHARYNGITIS

Few complications Complications:

Rheumatic Fever

Rheumatic Heart Disease

Post-streptococcal Glomerulonephritis

PHARYNGITIS: Comparing Outcomes

Treating Strep:Questionable benefits of antibiotics

• Preventing Rheumatic fever?

• Incidence of rheumatic fever was 3% if untreated.

• Studies prior to 1975 showed fourfold benefit.

• Dramatic decline in developed countries.

• Better recognition and treatment.

• Decline in prevalence of rheumatogenic strain.

• Rheumatic fever has almost disappeared. GO

For a child with a SORE THROAT:

STOP (Exclude from School)

GO (Back to Class)

HOME: IF FEVER, ILL, SUSPICIOUS FOR STREP

STREP: RETURN AFTER TREATED 12-24°

CLASS: IF NO FEVER, PAIN CONTROLLED

AND LOW INDEX OF SUSPICION FOR STREP

More studies are showing that the

student is NOT contagious 12 hours

after 1st dose of antibiotics.1

1 https://www.ncbi.nlm.nih.gov/pubmed/26295745

Diarrhea:When It’s Really Brown and Runny…

Diarrhea: An increase in the frequency, fluidity and volume of stool.

• Most often caused by a viral infection.

• Resolve within 72 hours. Loose stools may persist for days to weeks

Rotavirus: Stinks!

• Often preceding or concurrent viral illness. Runny nose. Cough. Red throat. Otitis. Weight loss.

• Seasonal epidemics.

• Vaccine is available.

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Bacterial Diarrhea

• Patients are more symptomatic: Abdominal pain.

Fever > 38.5°C.

Blood in stool.

Mucous in stool.

More than 8 BM’s in 24 hours.

Duration > 5 days.

• Single-source outbreak.

• Traveler's diarrhea.

Treating Diarrhea:

• Hydration: Fluids, fluids, fluids.

Dehydration: No tears, spit or pee.

• Fever: Treat the discomfort. NO ASPIRIN!

• NO antidiarrheal medicines

• Antibiotics (RARELY)

Only if culture positive.

Can prolong shedding virus in stool.

• Tincture of time.1. http://www.webmd.com/cold-and-flu/features/cold-cough-home-remedies-children

When Does Diarrhea Get You Sent Home?

• Fever, pain, ill, blood, mucous, cramping.

• Can’t control the diarrhea.

• History and comorbitities:

Crohn’s, Ulcerative Colitis

Irritable Bowel Syndromes

• Number of stools?

Bacterial and Viral Causes of GastroenteritisBacterial Viral

Fever >38.5° C Yes Unusual

Abdominal pain Yes Unusual

> 8 BM/24 hours Yes Unusual

Vomiting Unusual Yes

Duration > 5 days Yes No

WBC elevated Elevated No

Stool leukocytes and

mucous present

Yes (Shigella, Salmonella, Yersinia, Campylobacter,

invasive Escherichia coli)

No

No stool leukocytes:

Secretory diarrhea

Yes (Vibrio Cholerae, toxigenic E. Coli) No

Blood in stool Yes (Shigella, Salmonella, Yersinia, Campylobacter,

enterohemorrhagic Escherichia coli,

pseudomembranous colitis due to Clostridium difficile)

No

(Except rotavirus in

a preterm infant)

Shellfish consumption Yes (E coli, V cholera, Campylobacter, V. parahaemolyticus) Yes

(Norwalk agent)

Traveler’s diarrhea Yes (toxigenic E. coli, Salmonella, Shigella,) Unusual

(Norwalk virus and

rotavirus)

Single-source outbreak Yes (Salmonella, Shigella, Streptococcus aureus,

Bacillus cereus, Clostridium perfringens, Yersinia, E. coli)

Yes

(Norwalk agent)

Seasonal epidemics Unusual Yes (Campylobacter) Yes (rotavirus)

(Adapted from Infectious Disease: Disorders Caused by a Variety of Infectious Agents Ralph D. Feigin, Marshall L. Stoller) WORD

For a child with DIARRHEA:

STOP (Exclude from School)

GO (Back to Class)

HOME: Fever, pain, blood, mucous, ill,

FOLLOW THE RULE IN YOUR SCHOOL!

CLASS: if none of above, few stools, and

student can control the loose stools.GO

CAUTION

Antibiotics in Agriculture: 60+ Years of Experiment

• Sub-therapeutic doses of antibiotics are fed to animals.

• The animals gain more weight, FAST.

• Bacteria are more resistant.

• Antibiotics are now found in meat, milk and surface water.

Science Creative Quarterly, http://www.scq.ubc.ca Jen Philpott

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Antibiotics: Making Us Sick?Harms:

• Are of NO value unless a bacterial infection is highly suspected or proven.

• Increase risk of adverse events.

• Antibiotic resistance.

• Diarrhea.

• C difficile colitis.

• Allergic reaction, anaphylaxis, sudden cardiac death.

• Rash, Stevens-Johnson syndrome.

• Vomiting, abdominal pain.

• Disrupt intestinal microbial balance.

We are 99% Microbial

• The human body has about 100 trillion (100,000,000,000,000) bacteria on and in it.

• They create a “second genome” which exerts a huge influence on our health.

• It is “possible to reshape, even cultivate,

your second genome.”

Michael Pollan, Knight Professor of Journalism, University of

California, Berkeley, New York Times Magazine, May 15, 2013

Altering Our Intestinal Biome

Long-term adverse health effects:

• Inflammatory bowel disease

• Obesity

• Eczema

• Asthma and allergies.

Education Works

• Parental education has been shown to decrease the requests for antibiotics.

• Pediatrician education interventions reduced antibiotic prescribing ~25%.

• Only ~27% of children with acute respiratory tract infections have bacterial illness.

• Antibiotics were Rx in ~56% of visits.

• 11,400,000 Rx’s could have been avoided.

Thank You

Keep Washing Your Hands

Asthma

• Repeated episodes of acute, reversible bronchospasm.

• Three issues:

Airway swelling (edema).

Thick mucous.

Bronchospasm.

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NORMAL AIRWAY

Explaining Asthma:

AIRWAY SWELLING

LIKE BREATHING THROUGH A STRAW

THICK MUCOUS

SPASMS

M

Asthma Action Plan:

• SWELLING:

Inhaled Steroids, orals for exacerbation.

Nonsteroidal Anti-Inflammatory (montelukast).

• MUCOUS: Fluids and spitting.

• SPASMS:

Albuterol (Proair®, Ventolin®).

Ipratropium.

Asthma:

• Intermittent Asthma:

Symptoms only when sick or triggered.

No symptoms in-between.

Exercise-induced bronchospasm.

• Persistent Asthma:

Cough more than 2 days a week.

Cough more than 2 nights a month.

Interferes with normal activities.

Asthma

• CONTROL:

Breathing is good, no cough or wheeze.

Sleeping through the night.

Can do normal activities.

• RESCUE: Should NOT need > than 2 times/month.

May need prior to gym or exercise.

WITHOUT SPACER

©1998 Respironics Inc.

WITHSPACER

©1998 Respironics Inc.