Angel Solomon, MS PA‐CJune 2011
Infant & Childhood DevelopmentGross Motor3 month – head control4 month – roll over6 month – sit independently9 month – crawl12 month – walk18 month – climbs stairs, run24 month – kick ball
Infant & Childhood DevelopmentLanguage2 month – coos6 month – babbles12 month – mama, dada18 month – 4‐20 words24 month – combining words, 50% comprehensible
Infant & Childhood DevelopmentLanguage cont…3 year – 75% comprehensible4 year – 100% comprehensibleAge 7 or 8 – speech, language, articulations close to adult
Infant & Childhood Development
Social/Fine motor3 month – laugh6 month – reaches, feeds self9 month – indicates wants, pincer grasp12 month – imitates, follow 1 step commands
Infant & Childhood DevelopmentSocial/Fine motor cont…18 month – scribbles, feeds self w/spoon, potty training, stacks 3‐4 blocks24 month – follow 2 step commands, wash/dry hands3 yr – dresses with supervision
Newborn & Infant GrowthNewborns may lose up to 10% of their birth weight in the first week of lifeMost regain birth weight in about 10 daysFirst 6 months: gain about 1oz/dayAt 6 months: weigh 2x birth weightAt 12 months: weigh 3x birth weight, height 1.5x birth length
Childhood Growth
After 2 years of age: 2‐3 kg and 5‐7cm/yearAverage 30 month child weighs 30 pounds and is 30 inches tallAverage 4 year‐old weighs 40 pounds and is 40 inches tallWeight LOSS in a child is always suspicious
HEENTURIAcute Otitis MediaChonic Otitis MediaOtitis ExternaEpiglottitisCroup
StrabismusAmblyopiaAllergic RhinitisOral candidiasisENT Foreign Bodies
VIRAL URICommon in any age group; especially infants and toddlersLasts 7‐10 daysMCC: RhinovirusSymptoms:
Runny nose, nasal congestion, coryza, sneezing, mild conjunctivitis, sore throat, hoarseness, cough. Fever often presents for first 2‐3days
Tx: Cough and cold medications. No antibiotics!!!
OTITIS MEDIAAcute Otitis Media
Suppurative infection of the middle ear cavityMost prevalent in children between 6 and 24 mo
BacterialStreptococcus Pneumoniae (most common)Haemophilus influenzaMoraxella Catarrhalis
Viral Respiratory Syncytial VirusRhinovirus Influenza virus
Otitis Media
Risk FactorsDay Care AttendanceFormula Fed Infants (feeding position)Second hand cigarette smoke
Presentation & DiagnosisOften follows an upper respiratory tract infection(URI) by 1‐7 daysUsually presents with fever, poor feeding, pain and/or irritability, vomiting, ear pullingTM : bulging, red, landmarks not visualized, immobile (Pneumatic Otoscopy with evaluation of movement of TM)
AntibioticsDOC: Amoxicillin 40mg/kg/d OR 80‐90mg/kg/dIf antibiotic use or tx failure on Day 3: High dose amox, high dose amoxicillin/clavulanate, cefuroxime axetil or ceftriaxone
Chronic Otitis MediaDefinintion – recurring or persistent infection or inflammation for several months
Risk Factors ‐multiple ear infections, allergies, trauma, swelling of the adenoids
Sx – hearing loss, otorrhea, pressure, ear achePE: infxn, air‐fluid levels. discharge, perforationTx: Abx, Surgery (Myringotomy/Repair/Adenoids)Complications: Mastoiditis, Deafness
OTITIS EXTERNAInflammation of the skin in the outer ear canalCommonly caused by water trapped in the canal from swimming in lakes or poolsPathogens:
Staphylococcus aureusPseudomonas aeruginosa
Symptoms:Pain, purulent discharge, pain elicited with traction on pinna or tragus
Treatment:Antibiotic/Corticosteroid drops
Epiglottitis / Viral CroupEpiglottitis:
Most common pathogen is H. influenzaRAPID onset of sore throat, muffled voice, high fever, and drooling“Thumbprint sign” on lateral neck X‐rayAssume a critical airway and DO NOT examine the oropharynx unless able to intubate STAT
Viral Croup ‐ LaryngotracheobronchitisMost common cause of stridor in childrenPeak ages : 6 months to 3 years. Fall/Winter
Barking cough, URI symptoms, hoarseness, fever, inspiratory stridorPathogen: parainfluenza virus commonDiagnosis: H & P, season helpful (Fall/Winter)
<50% “steeple sign” on ant neck X‐rayTreatment: Hydration, Humidity! Steroids if severe
STRABISMUS
Definition: Misalignment of the visual axes of the eyes; results from imbalance in eye muscle movementsAffects 4‐5% of the US populationInfants may not develop coordinated eye movements until 3‐5 months of ageEye may deviate inward(esotropia), outward (exotropia), upward (hypertropia) or downward (hypotropia)Treatment: Glasses, occlusion, surgery
Courtesy of Dean John Bonsall, MD, FACS
AMBLYOPIA
Definition: decreases or loss of vision in one or both eyes in the absence of ocular or CNS pathologyInitiated by any condition that results in abnormal/unequal visual input between the “critical period” of birth to 8‐9 years of age (ie. Congenital cataracts, strabismus)Treatment is essential within the critical period; otherwise loss may be permanent
ALLERGIC RHINITIS
Inflammation of nasal and sinus packages ‐ associated with sneezing, runny nose, congestion, itchy eyesAffects 20‐30% of all kids and up to 75% of kids with asthmaKnow this triad: asthma/allergy/eczema!!!!!Physical exam pearls: “Allergic shiners”, “Allergic salute”Treatment: Removal of offending agents, oral/topical (spray) medicationsNote: Check nasal mucosa for polyps! In kids, polyps are suggestive of cystic fibrosis and should be investigated further
Oral Candidiasis
Etiology: Candida AlbicansSigns: adherent creamy plaques on buccal, gingival and lingual mucosaTx: NystatinRF: Inhaled steroids, Abx, immune system disorder
ENT FOREIGN BODIES
Commonly seen: Buttons, beads, marbles, nuts, toy parts, Bugs tooEar: Ear pain, drainage, hearing lossNose: Unilateral purulent rhinitis, persistent sinusitis, blocked nasal passage on examRemoval: Do not blindly probe! If visible, forceps, curette, Foley (inflated past foreign body), etc Restraint is essential to prevent further injury
LungsBronchiolitisPneumonia
ViralBacterialAtypical
Pertussis
Hyaline Membrane DiseaseCystic FibrosisForeign bodies
BRONCHIOLITIS
The most common lower respiratory illness in infants and young children less than 2 years old.Pathogen: Respiratory Syncytial Virus(RSV) in 50‐90% of casesSymptoms: Cough, mild fever, tachypnea, and wheezing.
Thick nasal congestionDiagnosis: RSV antigen nasal wash. CXR ‐ Hyperinflation
WBC ‐ Increases lymphocytesTreatment: Controversial
Nebulized albuterol commonly usedOral steroids if sx severeRibavirin has been used in hospitalized casesSynagis now used to prevent RSV in preemies
PNEUMONIA ‐ VIRALCommon in all age groups; follows URIEtiology:
MCC of pneumonia in children. RSV (MC), parainfluenza, & influenza viruses
Symptoms:URI precedes onset of cough Wheezing, grunting, nasal flaring common
Labs:WBC may be low, normal, or slightly elevated. A high WBC makes viral etiology unlikely
Imaging:CXR may show perihilar streaking, increased interstitial markings, peribronchial cuffing
Treatment:It is rarely possible to reliably differentiate viral from bacterial pneumonia based upon history, exam, labs or radiographsTherefore it is common for appropriate concomitant antibiotic coverage to be used for viral pneumonia in children
PNEUMONIA ‐ BACTERIALInflammation of the lung classified according to the infecting organism and siteOccurs in all age groups, but more commonly in children < 2 years oldCommon pathogens:
S. pneumoniae, Group A strepGroup B strep (neonates)
Symptoms:URI precedes abrupt onset of fever, chills, SOB, anorexia, cough, dyspneaN/V, abdominal/chest/shoulder pain typical, malaise
Pneumonia ‐ BacterialSigns:
tachypnea: reliable sign of pneumonia in kids!Cough, grunting, nasal flaring, Exam usually shows decreased breath sounds, rales, dullness to percussion, but can be normalWheezing unusual in bacterial pneumonia unless pt has baseline reactive airway disease
Labs:WBC >15,000 or greaterBlood cultures positive in 10‐15% of cases
Imaging:Lobar consolidation, patchy infiltrates commonMay see effusionsAtelectasis vs infiltrate ‐ often hard to tell
Treatment:Neonates: IV ampicillin/gentamycinOthers: penicillin. Amoxicillin, 2nd or 3rd generation cephalosporin
PNEUMONIA ‐ ATYPICALChlamydia pneumonia
Occurs between 2 weeks to 6 months of age. Peak incidence (>90%) by 8 weeksMost common cause of pneumonia in children under 6 months of age (25‐45% of cases)Pathogen: C. trachomatis (maternal STD)URI prodrome; nearly 100% afebrileStaccato cough, tachypnea, rales, conjunctivitisDx: Nasal wash, eosinophilia commonTx: Erythromycin. Hospitalization for those with paroxysmal cough, apnea, resp distress
Pneumonia ‐ AtypicalMycoplasma pneumonia:
Common over the age of 5 years, esp teensPathogen: Mycoplasma pneumoniaLong incubation: 2‐3 weeks
Symptoms: Gradual onset, Dry cough, progressing to productive. Fever, HA, malaise, Signs: Rales, bullous myringitisCXR: Middle and lower lobe infiltratesTx: Macrolides usually shorten course and may lessen severity of symptoms
PERTUSSIS“Whooping Cough”
Infants/toddlers; un‐/partially immunizedPathogen: Bordetella pertussis
Spread by teens/adults who are no longer immune Sx: 3 stages
Cattarhal: URI (1‐2 weeks)Paroxysmal: Staccato cough and ‘whoop’ on inspiration(1‐2 weeks)Convalescent: Dry cough (1‐2 weeks)
Dx: Hx, characteristic paroxysmal coughTx: Erythromycin
Hyaline Membrane Disease Cause: Deficiency of surfactantS&S: increased RR, cyanosis, expiratory gruntingDx: CXR shows hypoexpansion, B/L atelectasisTx: Oxygen, early intubation, ventilation
Surfactant replacement
CYSTIC FIBROSISMost common severe inherited disease in the Caucasian population ‐ 1:2500Resp symptoms: chronic cough or sinusitis, recurrent pneumonia, nasal polyps, clubbingGI symptoms: meconium ileus (20%), pancreatic insufficiency (85%), failure to thriveDx: Sweat chloride is the “gold standard” >60meq/L is abnormal. Genetic testingTx: ATB, pancreatic enzymes, bronchodilators, postural drainage. Mean survival age is increasing!
RESPIRATORY FOREIGN BODIES
Throat: Stridor, choking, cyanosis. (Can also occur if foreign body is in esophagus)Ball‐valve effect may cause hyperinflationHeimlech if suspected upper airway FB and respiratory distressRigid bronchoscopy if in lower airway.
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