Pediatric Refresher 2012

7/8/2012
Evidence Based Pediatric Treatment Guidelines 2012: Clinical Practice Strategies for the Retail Clinician
Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Owner Wright & Associates Family Healthcare Partner Partners in Healthcare Education
Facilitated by Partners In Healthcare Education and funded by Take Care Health Systems
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Another Great Resource for Pediatrics
PIHE 2012 www.brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 03-1022012011
Development & Anticipatory Guidance Anticipatory Guidance

Every visit from birth age 21 Specific guidance is based upon age
http://brightfutures.aap.org accessed 02-01-2010
Micronutrient recommendations
Vitamin D:
400 iu once daily Initiate in the neonatal period
Calcium:
500 mg daily (age 1 3 years) 800 mg daily (age 4 8 years) 1300 mg daily (age 9 18 years)
www.Nutrition.utk.edu/max_resources/maximize/ , accessed 03-05-2012
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Infants: rear-facing until two years of age Car Seat: after 2, should remain in a car seat for as long as possible, up to the maximum allowed by the manufacturers recommendations Should remain in booster seat until minimum of 8 years of age and 49 Rear seat until 13 years of age
www.aap.org/advocacy/releases/carseat2011.htm, accessed 03-05-2012
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Car Seat Recommendations
Eye Examinations and Vision

AAP recommendations
Begin vision screening as a newborn Formal screening at:
Age 3 years Age 4 years Age 5 years Age 6 years Age 8, 10, and 12 years Age 15 and 18 years
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USPSTF Hearing Screening Recommendations

The USPSTF recommends screening for hearing loss in all newborn infants All infants should have hearing screening before 1 month of age Those infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 months of age for confirmatory testing
These children should undergo periodic monitoring for 3 years
http://www.guidelines.gov/content.aspx?id=12640&search=hearing accessed 03-10-2011
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AAP Recommendations
Universal newborn hearing screening Screenings for hearing impairment should be performed periodically on all infants and children in accordance with the following schedule
Newborn Age 4, 5, 6, and 8 Risk assessments performed at all other wellchild visits
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/2/436 accessed 03-01-2011
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Dental Examination
AAP recommendations
Begin at age 12 months 18 months 24 months 30 months 3 years of age 6 years of age
Development & Anticipatory Guidance

Developmental Screening
9 months 18 months 30 months
Identify those infants and children with developmental disorders

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/3/645/F1 accessed 02-01-2010
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Autism Screening
Universal screening
Formal ASD screening on all children at 18 and 24 months regardless of whether there are any concerns Guidelines stress that providers need to ask/discuss any concerns that parents may have at every well-child visit
http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011
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M-CHAT Screening Tool

http://www.mchatscreen.com Conducted at 18 and 24 months Can learn to become certified autism screener
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Look for the Presence of Red Flags

No babbling or pointing or other gesture by 12 months No single words by 16 months No two-word spontaneous phrases by 24 months Loss of language or social skills at any age.
http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011
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Lead Screening
AAP recommendations
12 months or 24 months
Continued risk factor assessment throughout childhood
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sche d%20101107.pdf accessed 03-10-2011

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Anemia Screening
AAP recommendations
Age 12 months Hemoglobin or hematocrit
Obesity
U.S. Preventive Services Task Force recommends that clinicians screen children ages 6 to 18 years for obesity and refer them to programs to improve their weight status AAP
Beginning at age 2, calculate and plot BMI for all patients on a yearly basis.
Continued risk assessment throughout childhood
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%2 0Sched%20101107.pdf accessed 03-10-2011

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http://www.aap.org/obesity/USPSTF.html accessed 03-10-2012

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What To Do With Children

Prevention Plus
Children between the 85th - 94th percentiles BMI Encourage 5 servings of fruits and vegetables/day 2 hours or less of screen time 1 hour or more of physical activity 0 sugared drinks Also discuss the importance of family meal time, limiting eating out, consuming a healthy breakfast, and preparing own foods
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What To Do With Children

Structured Weight Management :
Used if prevention plus has not been effective BMI is between 95th - 98th percentiles This approach combines more frequent followup with written diet and exercise plans

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Diabetes: Screening in Children

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
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
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www.diabetes.org www.aace.com
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AAP Recommendations
Lipid screening should take place after age two but no later than age 10 for children at risk: family history of high cholesterol or heart disease Fasting lipid profile is recommended
If normal, repeat testing in three to five years
Pubertal Development
Female - normal onset:
8 13 years of age
Male normal onset:

9 14 years of age
For children > 8 years old and who have high LDL concentrations, cholesterol-reducing medications should be considered Children < 8 years of age with elevated cholesterol readings should focus on weight reduction and increased activity while receiving nutritional counseling
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;122/1/198 accessed 03PIHE 2012 15-2011
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General Health Counseling

Seatbelts Helmets Sunscreen Smoke Detectors Pool Safety Carbon Monoxide Guns Domestic Violence
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General Health Counseling

Drugs Alcohol Smoking
Remember School / sport physicals may be the only contact that the child has with a health care professional in a year
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Immunization schedule: aged 0 through 6 years United States, 2012
Immunizations
Pediatrics 2012;129:385-386
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2012 by American Academy of Pediatrics
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Immunization schedule: aged 7 through 18 yearsUnited States, 2012
Antipyretic
It is no longer recommended that an antipyretic such as ibuprofen or acetaminophen be administered prior to vaccine administration May reduce immunogenicity or response to vaccination May provide after vaccinations to attenuate fever or discomfort
Pediatrics 2012;129:385-386
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2012 by American Academy of Pediatrics
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ACIP Recommendations for Use of Meningococcal Conjugate Vaccine in Adolescents

Routine vaccination with quadrivalent meningococcal conjugate vaccine is recommended at 11 or 12 years of age1,2 A booster dose is recommended at 16 years of age1,a For adolescents who received the first dose of meningococcal conjugate vaccine at 13-15 years of age, a single booster dose should be administered preferably at 16-18 years of age1,a Persons who receive their first dose of meningococcal conjugate vaccine at or after 16 years of age do not need a booster dose1,a Unvaccinated persons 11-18 years of age should be vaccinated at the earliest possible health-care visit2 Routine vaccination of healthy persons not at increased risk for exposure to N meningitidis is not recommended after 21 years of age1
ACIP Guidance on Meningococcal Vaccines and College Enrollment1

Some schools, colleges, and universities require vaccination against meningococcal disease prior to enrollment Persons 21 years of age should have documentation of receipt of a dose of meningococcal conjugate vaccine not more than 5 years before enrollment If the primary dose was administered before the 16th birthday, a booster dose should be given prior to enrollment in collegea
Booster can be given at any time after the 16th birthdaya Minimum interval between doses of meningococcal conjugate vaccine is 8 weeksa
Reference: 1. CDC. MMWR. 2011;60(3):72-76.
References: 1. CDC. MMWR. 2011;60(3):72-76. 2. CDC. MMWR. 2007;56(41):794-795.
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ACIP Recommendations: 2-Dose Primary Series for Certain Persons at High Risk1,a
Two doses of meningococcal conjugate vaccine, 2 months apart, are recommended as a primary series for: Persons 2-55 years of age with persistent complement component deficiencies or functional or anatomic asplenia
Booster vaccination then needed every 5 years
ACIP Recommendations for Meningococcal Conjugate Vaccination of Infants1

In 2011, the ACIP recommended meningococcal conjugate vaccine for infants 9 months through 23 months of age who are at high risk for meningococcal disease High-risk infants include those who:a
Have persistent complement component deficiencies (eg, C5C9, properdin, factor H, or factor D) Are at risk during a community or institutional outbreak Are traveling to an area where meningococcal disease is epidemic or hyperendemic
Persons infected with human immunodeficiency virus (HIV)

For HIV-infected persons 11-18 years of age: Give booster at 16 years of age if primary dose is given at 11-12 years of age Give booster at 16-18 years of age if primary dose is given at 13-15 years of age No booster needed if primary dose is given at 16 years of age
The recommendation is for 2 doses, given 3 months apart

a
Does not include infants with functional or anatomic asplenia.

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 only Age limit: < 26 years of age
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HPV4 Vaccine
Series of 3 injections
Day 0, 2 months, 6 months Minimum 28 days from 1st 2nd injection Minimum 6 months from 1st 3rd injection
.5 ml injection IM injection into deltoid
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Additional Indication for HPV4

Indicated to reduce risk of genital warts in males Ages: 9 years - < 26 years of age Universal recommendation:
Ages: 9 - < 21 years of age Permissive: 22 26 years
Additional Approval
HPV4
Prevention of anal cancer and associated precancerous lesions due to human papillomavirus (HPV) types 6, 11, 16, and 18 in people ages 9 through 26 years 78 percent effective in the prevention of HPV 16- and 18-related AIN
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Additional HPV2 Vaccine

Cervarix Approval age: 10 25 years Bivalent vaccine (strains 16 and 18)
May have some protection against stain 31
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
Decreases risk of cervical cancer ACIP placed vaccine on an interchangeable state with Gardasil Schedule: day 0, day 1 month and day 6 months
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When child presents with a fever of 5 7 days or less, must consider:

Viral vs. Bacterial infections Bacteremia Sepsis
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Worrisome Findings: Consider Hospitalization

Altered LOC Abnormal breathing Tachycardia in presence of significant findings Significantly elevated temperature Petechiae Cyanosis Pallor Delayed capillary refill (> 2 seconds) Poor muscle tone
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Management of Fever
Antipyretics
May mask signs and symptoms of serious conditions Side effects may occur from these medications Do not alter course of illness
Benefits
Good when fever is > 103 Always recommend in children with history of febrile seizure May make more comfortable
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Management of Fever
Options for treatment (weight/age dosing)
Acetaminophen Ibuprofen
Clinical Pearl:
Caution regarding cool sponge baths Education:

Monitor closely Reinforce when to call or return Avoid aspirin and related products Increase fluids
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Document visual acuity on all eye complaints

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Hordeolum
Etiology
Obstruction of the glands of Zeiss Staphylococcal aureus is the most common causative organism
Hordeolum
Physical examination
Erythematous, tender nodule on the margin of the eyelid Surrounding edema
History
Swollen, red, painful lesion on the lid margin Itchiness of the eyelid
Treatment
Warm compresses-20 minutes qid Antimicrobial ointment or drops Good eye hygiene and handwashing
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Hordeolum
Internal Hordeola
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Viral Conjunctivitis
Etiology
Adenovirus is the most common cause
40 strains identified
Signs
Normal visual acuity, PERRLA, EOMI, Fund nl Mucoid-slightly watery discharge Mild, diffuse injection Preauricular lymphadenopathy
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 PIHE 2012 Often bilateral
Treatment
Symptomatic only Cool compresses Strict eye hygiene
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Bacterial Conjunctivitis
Etiology
Staphylococcus aureus Streptococcus pneumoniae/pyogenes Haemophilus influenzae Neisseria gonorrhea
Symptoms
Redness, swelling, purulent discharge, itching No symptoms until eye complaints began
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Signs
Normal visual acuity, PERRLA, EOMI, Fund nl Diffuse injection No ciliary injection Unilateral at onset
Treatment
Topical antimicrobials x 5-7 days Warm compresses qid x 10-20 minutes Strict eye hygiene given contagion
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Conjunctivitis
Viral
Palpable preauricular node Watery discharge Mild-moderate conjuctival injection URI symptoms Bilateral
Allergic Conjunctivitis
Two types of allergic conjunctivitis
Seasonal and perennial
Bacterial
Non-palpable nodes
GC and Chlamydia +
Seasonal is most common and caused by the following triggers

Pollens Grass Ragweed
Purulent discharge
GC-Mucopurulent
Moderate conjunctival injection Unilateral at onset
Perennial persists all year and is caused by indoor allergens, such as dust mites
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Signs and Symptoms

Symptoms
Itching Watery stringy-like clear discharge
Signs
Injected conjunctiva Other physical examination findings such as:
Dennies lines Allergic shiners Allergic facies Allergic crease
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Treatment
Systemic and/or topical antihistamines relieve acute symptoms due to interaction of histamine at ocular H1 and H2 receptors Examples of topical antihistamines include: epinastine (Elestat) and azelastine (Optivar) Vasoconstrictors are available either alone or in conjunction with antihistamines to provide shortterm relief of vascular injection and redness
Common vasoconstrictors include naphazoline, phenylephrine, oxymetazoline, and tetrahydrozoline
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Treatment
Mast cell stabilizers include cromolyn sodium and lodoxamide (Alomide), Olopatadine (Patanol), nedocromil (Alocril) Nonsteroidal anti-inflammatory drugs (NSAIDs) act on the cyclooxygenase metabolic pathway and inhibit production of prostaglandins. One example is: ketorolac tromethamine (Acular)
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Ear Conditions
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Variations of Tympanic Membrane Normal TM

Acute OM Otitis Media with Effusion
Acute Otitis Media

75% of otitis media infections are viral S. pneumoniae is the most common bacterial pathogen Less common pathogens
H. influenzae M. catarrhalis
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Bullous Myringitis
Mycoplasma Intensely painful Treatment is with a macrolide
Diagnosis of AOM
History of acute onset Identify presence of middle ear effusion
Bulging TM Decreased or absent mobility of TM Air-fluid level present Otorrhea
Identify signs of middle ear inflammation

Erythematous TM Otalgia which interferes with function/sleep
PIHE 2012 PIHE 2012 www.aap.org accessed 02-010201 -2010
Criteria for Initial Treatment or Observation in AOM

Age Certain diagnosis Uncertain diagnosis Age
Criteria for Initial Treatment or Observation in AOM

Certain diagnosis Uncertain diagnosis
=>2 y
6 momo- 2 y Antibacterial therapy Antibacterial therapy if severe illness; observation option if nonsevere illness
Antibacterial therapy if severe illness; observation option if nonsevere illness
Observation option
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Antibacterial Agents in AOM

Temp = 39C and/or Severe Otalgia No Clinically defined treatment failure at 4848-72 hours after initial management with observation option or individual who is a candidate for treatment at initial visit
Recommended Alternative for Penicillin Allergy Temp = 39C and/or Severe Otalgia
Recommended Antibacterial Agents in AOM

Clinically defined treatment failure at 4848-72 hours after initial management with antibacterial agents
Recommended Alternative for Penicillin Allergy
Amoxicillin
8080-90 mg/kg/day
NonNon -Type I: Cefdinir, Cefuroxime, or Cefpodoxime Type I: Azithromycin, Clarithromycin Ceftriaxone

1 or 3 days
No
AmoxicillinAmoxicillin -clavulanate
90 mg/kg/day of amoxicillin component with 6.4 mg/kg.day of clavulanate
NonNon -Type I: Ceftriaxone

3 days
Yes
AmoxicillinAmoxicillin -clavulanate
90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate
Type I: Clindamycin Tympanocentesis, Tympanocentesis , clindamycin
Yes
Ceftriaxone
3 days
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Types of Hypersensitivity
Non-Type I
Rash
Remember
For children with OM and tympanostomy tubes:
You may also utilize topical medications Floxin Otic (Ofloxacin) 0.3% solution
Age 1 - 12 years: 5 drops into affected ear bid x 10 days
Type I
Urticaria
Ciprodex (Ciprofloxacin):
6 months and up: 4 drops into the affected ear bid x 7 days
www.aap.org
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Duration of Treatment for AOM

Results
Similar response in all patients between shortcourse (eg, 5 days) and standard-course (eg, 10 days) therapy Patients <2 years old and those in a daycare setting may achieve better results with 10-day therapy Current recommendation: 5-7 days for all others
Hoberman et al. Pediatr Infect Dis J 1997;16:463; Cohen et al. J Pediatr 1998; 133:634; Pessey et al. Pediatr Infect Dis J 1999;18:854; Cohen et al. Pediatr Infect Dis J 1999;18:403.
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Otitis Media with Effusion

Fluid in the middle ear No signs and symptoms of AOM
Air fluid levels Dullness of TM Decreased movement of TM
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010

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OME
Treatment:
OME
Observation as a treatment option Majority up to 90% will resolve within 3 months without intervention If still present at 12 weeks may need hearing evaluation, referral to ENT High risk individuals may be candidates for myringotomy
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010

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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
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Otitis Externa
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Otitis Externa
Symptoms
Unilateral ear pain Discharge from the ear Low grade fever Recent history of swimming or placing something in ear Pain with tragal movement Redness around ear Decreased hearing
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Otitis Externa
Signs
Erythematous, edematous canal Pain with tragal/pinna movement Yellow/green discharge Foreign body Pre or postauricular lymphadenopathy
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Otitis Externa
Plan
Diagnostic
None Can check culture
Otitis Externa
Plan
Therapeutic
Warm compresses NSAIDS/Tylenol Prednisone Auralgam Wick
Therapeutic
Remove foreign body Irrigate canal Cortisporin Otic Ear Solution: 4 drops qid into affected ear x 5 days Ciprodex 3 4 drops tid into affected ear x 7 days
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Otitis Externa
Plan
Educational
Avoid prolonged water exposure - ear plugs Ear wax removal kits Prevention: Oil into canal; Vaseline on cotton ball No Q tips in ear Try to remove all water after bathing by manipulating ear
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PHARYNGITIS
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Pharyngitis Epidemiology
Group A Beta Hemolytic Strep
Most interest because of its association with severe complications Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis - complications
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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
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Exudative pharyngitis
Exudative pharyngitis Differentials include: Strep pharyngitis Peritonsillar abscess Mononucleosis Viral pharyngitis
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
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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
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Remember Children with mono have strep pharyngitis 50% of the time
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Pharyngitis
Plan
Therapeutic: Strep Pharyngitis
PCN VK-standard Treatment is for 10 days Warm water gargles Tylenol/NSAIDs
Peritonsillar Abscess
Generally begins as an acute febrile URI or pharyngitis Condition suddenly worsens
Increased fever Anorexia Drooling Dyspnea Trismus
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Educational
Contagion Quick improvement Discard toothbrush
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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
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
If respiratory distress is severe, do not examine the pharynx

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ENT consult is essential Usual management

IV antibiotics Inpatient management PIHE 2012
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Viral Upper Respiratory Infection

Caused by the rhinovirus, adenovirus or coronavirus Transmitted through respiratory droplets Most common ages: 4 7 years Begins with sore throat, low grade fever and progresses on to include nasal congestion and a cough Typically lasts 3 14 days
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Treatment
Mainly symptomatic
Avoid cough and cold medications in individuals < 2 years of age
Consider the following:

Decongestants First generation antihistamines Cough suppressants Guafenisen products Chicken soup PIHE 2012
General Signs and Symptoms of Respiratory Distress

Respiratory rate which is > 50% above upper limits of normal for age Intercostal retractions Nasal flaring Substernal retractions Grunting with breathing Cyanosis/pallor
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Asthma and Asthma Exacerbation

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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
Asthma is...
A disease of:
Inflammation
Primary Process
Hyperresponsiveness Airway bronchoconstriction Excessive mucous production
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Epithelial Damage in Asthma
Diagnosis of Asthma
PIHE 2012 Jeffery P. In: Asthma, Academic Press 1998.
Normal
Asthmatic
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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.
Diagnosis of Asthma
History and Physical Examination Pulmonary Function Tests Monitoring:
Peak Flow Meters
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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Symptoms and Signs of Asthma in Children

Coughing, particularly at night Wheezing Chest tightness SOB Cold that lingers x months with a persistent cough
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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.
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Stepwise Approach for Managing Asthma in Patients Aged 12 Years: NAEPP EPR-3 Guidelines
Severe Persistent Mild Persistent Step 2
Preferred: Low-dose inhaled corticosteroid (ICS) Alternative: Mast cell stabilizer (Cromolyn nedocromil), leukotriene receptor antagonist (LTRA), or theophylline Wright, 2012
Intermittent Step 1
Preferred: SABA prn
Moderate Persistent Step 3

Preferred: Medium-dose ICS or Low-dose ICS + LABA Alternative: Low-dose ICS and either LTRA, theophylline, or zileuton
Step 6 Step 5 Step 4

Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS and either LTRA, theophylline, or zileuton Preferred: High-dose ICS + LABA and omalizumab use can be considered for patients who have allergies. Preferred: High-dose ICS + LABA + oral corticosteroid and consider omalizumab for patients who have allergies
Acute Asthma Exacerbation Management

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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
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
Meds: none Allergies: NKDA PMH: Bronchiolitis: age 6 months required hospitalization PIHE 2012
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Acute Asthma Exacerbation

Measure Spirometry vs. Peak Flow FEV1 is most important number
>80% predicted 50% 79% of predicted < 50% of predicted
Spirometry Results FEV1 = 62% of predicted FEV1/FVC = 90% What does this mean for our patient?
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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
Prednisone
Multiple products available Prelone, Orapred, Prednisone
1 mg/kg daily (may split dosage)
Can repeat x 1 2 provided patient tolerates

Xopenex 1.25 mg nebulizer Reassess spirometry or peak flow after
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Example: Prednisone 10 mg bid x 3 - 10 days No taper necessary

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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
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Patient Education
Have plan in place for next URI Preventative therapy? Environmental modification Daily peak flows
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Management of Moderate Exacerbations: Response from Emergency Treatment

Good Response Symptom relief sustained x 1hr; FEV1 or PEF 70% D/C home Continue SABA & oral corticosteroid Consider inhaled corticosteroid (ICS) Patient education / asthma action plan
Management of Moderate Exacerbations: Response from Emergency Treatment

Incomplete Response Mild-moderate symptoms, FEV1 or PEF 40-69% SABA, oxygen, oral or IV corticosteroids Can D/C home Poor Response Marked symptoms, PEF <40% Repeat SABA immediately ED / 911; oral corticosteroid
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Bronchiolitis
Bronchiolitis is the most common lower respiratory tract infection in infants and is usually caused by a viral infection Most common cause: respiratory syncytial virus RSV is responsible for > 50% of all cases Other causes: adenovirus and influenza Most commonly seen in the winter and spring
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Bronchiolitis
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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
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Burden of Illness
Typically, bronchiolitis is a mild illness Risk factors for more severe illness include:
Prematurity Heart or lung disease Weakened immune system
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Complications of Bronchiolitis
Hospitalization Respiratory distress Children with this condition are more likely to develop asthma later in life
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
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Signs and Symptoms

Cough worsens Wheezes frequently occur
High pitched sounds indicating a difficulty with air movement
Incubation Period and Duration

Incubation period is:
Days 1 week This is dependent upon which virus is responsible for the infection
Worsening respiratory distress may occur

Retractions Flaring of the nostrils Irritability Tachycardia and tachypnea
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Duration of symptoms
Typically 7 days but children with severe cases may cough for weeks
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Treatment
Symptomatic treatment is the most common treatment
Increased fluids Cool mist vaporizer to thin the secretions Tilting the childs mattress up may be beneficial
Pharmacotherapy Corticosteroids Inhaled corticosteroids SABA (albuterol or similar)
Antibiotics are not helpful

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Bronchitis
Definition: Inflammatory condition of the tracheobronchial tree
Acute bronchitis
Bronchitis
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Most cases of acute bronchitis are viral (90-95%) 5% are bacterial
Most frequent cause of bacterial bronchitis atypical pathogen (i.e. mycoplasma) PIHE 2012
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Treatment for Bronchitis

Symptomatic Increase fluids Steam Guiafenesin or similar First generation antihistamine Cough syrup usually not helpful or effective
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Bronchitis
Treatment
Antibiotics rarely needed
If needed, atypical pathogen coverage
Prednisone
Short, non-tapering burst is often very effective i.e. 5 days
SABA
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Pertussis
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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. 136
Pertussis: Highly Communicable, Frequently Overlooked

Acute respiratory tract infection caused by Bordetella pertussis (gram-negative aerobic bacillus)1 Highly communicable (90%-100% secondary attack rate among susceptibles)2,3 Morbidity in all ages, especially infants1,2 The cause of 13%-17% of cases of prolonged cough in adolescents and adults4 Adolescents, adults with unrecognized or untreated pertussis contribute to the reservoir of B pertussis in the community and pose a risk of transmission to others1
References: 1. Centers for Disease Control and Prevention (CDC). MMWR. 2005;55(RR-14):1-16. 2. CDC. MMWR. 2006;55(RR-17):1-37. 3. Long SS: Pertussis (Bordetella pertussis and Bordetella parapartussis.) In: Kliegman RM, Behrman PIHE 2012 Philadelphia, PA: Saunders Elsevier;2007:1178RE, Jenson HB, Stanton BF, eds, Nelson Textbook of Pediatrics . 18th edition. 1182. 4. Cherry JD. Pediatrics. 2005;115(5):1422-1427.
Reported Cases of Pertussis Are Highest in Adolescents and Adults

~10,000-25,000 cases of pertussis are reported in the US every year1 ~60% of reported cases occur among adolescents and adults2 Reported cases are the tip of the iceberg Estimated actual cases among adolescents and adults: 800,000-3.3 million per year3
Eye of Science /Photo Researchers, Inc.
Courtesy of the Centers for Disease Control and Prevention (CDC).
Despite increasing awareness and recognition of pertussis as a disease that affects adolescents and adults, pertussis is overlooked in the differential diagnosis of cough illness in this population.4
References: 1. CDC. (Published July 9, 2009 for 2007). MMWR. 2007;56(53):1-94. 2. CDC. Data on file (Pertussis Surveillance Reports), 2003-2008. MKT 17595 (2003-2006); MKT18596 (2007); MKT 18761 (2008). 3. Cherry JD. PIHE 2012 Pediatrics. 2005;115(5):1422-1427. 4. CDC. MMWR. 2005;55(RR-14):1-16.
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The Very Young are Very Vulnerable to Complications of Pertussis

Pertussis complications, hospitalizations, and deaths1
No. with pertussisa Hospitalization Pneumonia Seizures Encephalopathy Death 7203 1073 3137 4543 301 324 847 92 168 103 7 36 15 1 3 56 1 1 Age <6 months 6-11 months 1-4 years
a
Transmitting Pertussis to Infants Is a Family Matter1

Multicenter study in France,
Germany, Canada, US
Study population: 95 infants 6

months of age with labconfirmed pertussis
Friend/Cousin 10%
Grandparent 6%
Part-time caretaker 2%
Household members were

responsible for 76%-83% of transmission to infants in 44 cases where a source could be identified
Aunt/Uncle 10% Sibling 16%
Mother 37%
Individuals with pertussis may have had 1 or more of the listed complications. Data are for 1997-2000.
Unvaccinated or incompletely vaccinated infants aged <12 months have the highest risk for severe and life-threatening complications and death.2
References: 1. CDC. MMWR. 2002;51(4):73-76. 2. CDC. MMWR. 2005;54(RR-14):1-16.
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. PIHE 2012
Father 18%
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Reference: 1. Wendelboe AM, et al. Pediatr Infect Dis J. 2007;26(4):293-299.
October 2010 ACIP Recommendations

Recommendations for Use of Tdap Vaccine
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
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All individuals 65 years of age and older Should receive Tdap
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
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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 144 Wright, 2012 JH, et al. J Perinatol. 2010;30(2):93-97.
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ACIP Recommendations
ACIP voted to recommend that pregnant women who have never received the Tdap vaccine should be immunized during their second trimester (after 20 weeks gestation) or during their third trimester rather than in the immediate postpartum period If not done at that time, mothers who have not already
received Tdap, it is recommended as soon as feasible in the immediate postpartum period1 Vaccination should occur before discharge from the hospital or birthing center
http://www.aafp.org/online/en/home/publications/news/news-now/health-of-the-public/20110629acipnewreqs.html accessed 01-15-2012 145 Wright, 2012
Diagnostic Tests for Pertussis

NP culture on special media PCR Serologic tests Increased WBC with an absolute lymphocytosis DFAvariable sensitivity/specificity
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Copyright 2005 Nucleus Medical Art. All rights reserved. www.nucleusinc.com.
(Regan-Lowe, BordetGengou)
Treatment of Cases and Chemoprophylaxis of Close Contacts

Erythromycin estolate or erythromycin ethylsuccinate (EES) 40-50 mg/kg/day (max 2 g/day) in 2-4 divided doses for 7-14 days1* Azithromycin 10-12 mg/kg/day (max 500mg/day) 1 dose/day for 5 days Clarithromycin 15-20 mg/kg/day (max 1g/day) in 2 divided doses for 7 days
Reference: 1. Halperin SA. Pertussis Control in Canada [letter]. CMAJ. 2003;168(11):1389-1390. * Use caution when using macrolides, especially erythromycin, in infants less than 2 weeks old. Azithromycin may be given as 10-12 mg/kg/day (max 500 mg/day) on day 1 and 5 mg/kg/day (max 250 mg/day) on days 25.
Treatment of Cases and Chemoprophylaxis of Close Contacts (contd)

For patients allergic to macrolides: Trimethoprim-sulfamethoxazole 8mg TMP/40mg SMX/kg/day (max 320mg TMP/1600mg/day) in 2 divided doses for 14 days1 All of these agents reduce transmission of B pertussis and ameliorate early symptoms2 No antibiotic lessens the severity or shortens the duration of cough in patients who are already experiencing paroxysmal episodes1 Penicillins/cephalosporins are not effective
References: 1. Edwards KM, et al. In: Plotkin SA, et al, eds. Vaccines. 1999:293-344. PIHE 2012 2. CDC. The Pink Book, 7th ed. 2002:75-88. Available at: www.cdc.gov/nip/publications/pink/pert.pdf. Accessed March 15, 2005.
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Websites with Vaccine Information

www.pertussis.com www.cdc.gov/nip/vacsafe www.cispimmunize.org www.vaccine.chop.edu www.vaccineprotection.com
Stridor
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Stridor
Few conditions in pediatrics are as emergent and potentially life threatening as an upper airway obstruction Rapid identification and treatment is essential
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Differential Diagnosis for Stridor

Differential
Laryngotracheobronchitis (croup) Mechanical obstruction (birth) Foreign body aspiration Peritonsillar abscess Epiglottitis Angioedema
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Croup
Causes:
Usually caused by a virus RSV, Parainfluenza or Rhinovirus
Croup
Characteristics:
Inflammation and edema of the pharynx and upper airways Narrowing of the subglottic region + laryngospasm is frequently seen
Subglottic narrowing
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Croup
Presentation:
Mild URI symptoms x 24 48 hours
Rhinorrhea, cough, low grade fever, sore throat
Croup
Presentation:
May have wheezing on auscultation Suprasternal and subcostal retractions are most common Tachycardia and tachypnea are frequently present Hypoxemia may occur Severity and course varies significantly but illness usually lasts about 3 days 1 week
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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 PIHE 2012
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Croup
Treatment:
Exposure to a cool night; child often improves on the way to the ED Humidification or mist may be helpful Aerosolized racemic epinephrine can be helpful
Very short acting agent delivered via nebulizer
Treatment
Symptomatic treatment is the most common treatment
Increased fluids Cool mist vaporizer to thin the secretions Tilting the childs mattress up may be beneficial
Nebulizer with albuterol or Xopenex may offer some benefit Inhaled corticosteroids/prednisone is frequently beneficial
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Antibiotics are not helpful

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Severe Croup
Airway management may be essential Possibilities includes tracheostomy vs. intubation depending upon severity
Rarely done any longer although may be needed if child is severe
Pneumonia
Definition: Acute infection of the lung parenchyma Can occur as a result of:
Aspiration Viruses Bacteria
Children < than 4 years

Consider: RSV and parainfluenza Consider S. pneumoniae and H. influenzae
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Pneumonia
Children > 5 years
Mycoplasma, S. pneumoniae, Chlamydia pneumoniae Diagnostic
Pneumonia
Chest X-ray is recommended for all suspected cases of pneumonia
Treatment
4 months 4 years
Amoxicillin (90mg/kg/day), Amox/clavulanate, Azithromycin (10mg/kg day one, then 5mg/kg d 2-5) or Clarithromycin
Vital signs Respiratory distress Auscultate lungs (egophony, bronchophony) Palpate for tactile fremitus
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5 years and older

Amoxicillin (90mg/kg/day), can add macrolide to regimen Alternative: amoxicillin / clavulanate
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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
Cause of Chest Pain in Children

Precordial Catch (Texidors twinge)
Most common cause of chest pain An innocent cause of chest pain
Very typical history:

Sporadic (entirely random) LSB (always same place) Quality sharp Radiation: fingerpoint Mild severe Lasts < 2 minutes Respirations make it worse!!
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Cardiac Causes of Chest Pain

Congenital heart conditions i.e. cardiomyopathies Arrhythmias must also be considered Pericarditis vs. myocarditis must also be considered Important:
Comprehensive history and physical examination
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Murmurs
Innocent murmurs will be heard in up to 50% of school aged children Goal to make sure that you do not miss a serious cardiac anomaly Important questions:
Any sob with exercise? Any dizziness or syncope with exercise? Any family history of sudden cardiac death?
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Characteristics of Benign Murmurs

No radiation Systolic Grade < III Does not interfere with S1 and S2 Decreases with sitting or standing Equal femoral and radial pulses Normal PMI Normal history and physical examination
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Characteristics of Pathologic Murmurs

Radiation Diastolic Grade > IV Interferes with S1 and/or S2 Increases with sitting or standing Unequal femoral and/or radial pulses Displaced PMI Abnormal history
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Work up for Pathologic Murmur

Cardiac consultation Echocardiogram If HCM is suspected, must deny sports participation pending additional work-up
Increases with standing Systolic in nature Often accompanied by shortness of breath with exercise
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GI/GU
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Acute vs. Chronic Abdominal Pain

Acute gastroenteritis number one cause of acute abdominal pain in children Other causes of acute pain:
RLL and LLL pneumonia, constipation, UTI, appendicitis, mittelschmerz, ectopic pregnancy and ovarian cysts
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Causes of Chronic or Recurrent Pain

Constipation Musculoskeletal pain Lactose intolerance vs. celiac disease Colitis vs. Crohns IBS
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Statistics
Common complaint worldwide
Diarrhea
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Millions of individuals develop diarrhea every year
Young and old individuals at increased risk from this condition

Increased risk of dehydration Increased risk of death
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Pathophysiology
4 basic mechanisms causing diarrhea
Retention of water within the intestine
Malabsorptive syndrome; lactose intolerance Maalox can produce diarrhea through this mechanism
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
Excessive secretion of water and electrolytes into the intestinal lumen

Cholera; E. Coli, Crohns disease, laxatives
Release of protein and fluid into the intestinal mucosa

Ulcerative colitis, Crohns disease, Infections
Altered intestinal motility resulting in rapid transport through the colon

IBS, Scleroderma
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History
Any other family/friends ill? Any recent trips/camping? Food intake?
Any nonpasturized ciders? Any beef? Uncooked meats? Mayonnaise?
Symptoms
Sudden onset Frequent bowel movements Loose, watery stools Bloody stools Abdominal cramping Thirst Decreased urination Dizziness Fatigue
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Medications?
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Generally unremarkable Tachycardia Poor turgor Orthostatic signs Hyperactive bowel sounds (borborygmi) Tender abdomen Heme positive stool, possibly (E. Coli) Fecal impaction
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Acute Gastroenteritis
Symptoms
Abdominal pain described as colicky, diffuse, crampy May have vomiting Headache Fever and chills Profuse diarrhea often helps to differentiate it from appendicitis
Please remember that 15% of children with an appendicitis will have significant diarrhea
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Gastroenteritis
Signs
Temperature Diffuse tenderness No obturator, psoas or markles sign Dehydration
No urination or tears in 6-8 hours constitutes dehydration in children
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Gastroenteritis
Diagnosis
History and physical examination Fecal leukocytes
Salmonella, Shigella, Amoeba and Campylobacter all invade the intestinal mucosa and therefore cause leukocytes Inflammatory bowel disease (Colitis, Crohns) E. coli, viral etiologies do not generally produce these cells
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Gastroenteritis
Stools for O&P
Entamoeba histolytica Giardia lamblia
Gastroenteritis
Treatment
Fluids BRATT diet
Avoid lactose
Stools for C&S

Salmonella or Shigella Need to request specific tests for E. Coli, Yersinia, and Campylobacter
Antibiotics
Depending upon the pathology-antibiotic regimen varies
C. difficile
Previous antibiotic therapy
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IV rehydration Hospitalization Anti-motility agents (controversial)

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Constipation
Normal frequency of BMs: 3 / day 3 per week Focus is shifting more toward comfort with BMs rather than number Most common GI complaint in the US Always ask regarding following:
Weight loss, blood in stool, abdominal pain, anorexia, vomiting, anemia
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Constipation
Options for treatment
Fiber intake Polyethylene glycol (Miralax) Lactulose Milk of Magnesia Behavioral modification
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Don...
Don is a 17yowm who presents with an 2 day history of worsening abdominal pain. Woke him from sleep today. Epigastric at onset. Now seems lower in right side of abdomen. Associated with nausea and vomiting for the past 2 hours and a temp of 100. Denies bowel changes, urinary symptoms. Meds: none; Allergies: NKDA What is going on with Don?
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Appendicitis
Inflammation/Infection of the Appendix
Can lead to ischemia and perforation of the appendix
Etiology
Most common age: 10-19 years Incidence: 1.1/1000 Persons each year Males>females Whites>Nonwhites Summer-most common time of year PIHE 2012 Midwest-highest incidence
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
History of a patient with appendicitis

Careful history is the most important aspect
Individual is usually a teen or young adult
Classic presentation: awakens in the night with vague periumbilical pain

Worsens over the period of 4 hours Subsides as it migrates to the RLQ Worsened with movement, deep respirations, coughing
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Clinical Pearl The presence of pain before vomiting is highly suggestive of appendicitis. Diarrhea before pain is more likely to be gastroenteritis.
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Abdominal Examination
Tenderness at McBurneys point
1/3 the distance between the anterior iliac spine and the umbilicus
Guarding
Contraction of the abdominal walls Frequently present
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Rigidity
Important predictor of appendicitis Involuntary spasm of the abdominal musculature Caused by peritoneal inflammation
Rebound tenderness
Press on area above the pain Suddenly withdraw fingers
Rovsings 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 lift thigh against your hand that you have placed above the PIHEknee 2012
Markles sign
Heel-drop jarring test
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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
Laboratory/Radiologic Testing
CBC with differential
Normal wbc count doesnt rule-out the diagnosis White blood cell count may actually decrease Look for wbc left shift Elevated wbc Elevated neutrophils Elevated bands
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Internal Examination
Consideration to an ovarian cyst
Rectal Examination
May be considered
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Laboratory/Radiologic Testing
Urinalysis CT Scan
Within past 2 years, new focused appendiceal/helical/spiral CT technique has been developed Decrease in the laparoscopy rate Ultrasound can still be performed but limitations exist
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UTI
Gram negative bacilli are the most common pathogens (Escherichia coli) Staphylococcus saprophyticus more likely in young, sexually active women Preschoolers and young children will likely present with symptoms similar to an adult
Dysuria, urgency, frequency
Must r/o or consider pyelonephritis

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UTI
Urinary dipstick findings
Leukocytes Nitrites RBCs
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
Treatment
Trimethoprim/sulfamethoxazole (8 10 mg/day of trimethoprim Cefixime (Suprax) in children > 6 years Cefpodixime (Vantin) Treatment: 7 days PIHE 10 2012 days
Differentials (particularly if dry in past)

Urinary tract infection Emotional issues (divorce, new baby) Type 1 diabetes Neurologic abnormalities Constipation
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Enuresis
Treatment Options
DDAVP (Nasal spray no longer approved) Tricyclic antidepressants (caution advised) Bed wetting alarm Bladder training Constipation treatments
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 sports participation

Butto find any problems that might worsen with particular activities
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Millions of Young Athletes

Millions of young athletes are involved in a variety of activities
Goals of the Preparticipation Physical Examination

Pre-participation physical is also not a substitute for routine primary care
However, the preparticipation physical examination is the only contact with a health care provider for 78% of all athletes
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Kids Just Want to Have Some Fun!!
Frequency
AAP recommends examinations every 2 years Many schools have different recommendations
http://www.emedicine.com/sports/TOPIC156.HTM#section~TimingFrequencyandType sofEvaluations accessed 02-10-2010
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Preparticipation Physical Examination

Guidelines issued by AHA, AAFP and AAP Standardized forms recommended to include history and physical examination Biggest concern
Cardiac pathology
Most common abnormality

Orthopedic abnormality
http://pedsinreview.aappublications.org/cgi/content/extract/22/6/199 accessed 02-10-2010
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Sprains/strains
Most frequently encountered in children:
Ankles number 1 Fingers Knees
Treatment of Ankle Sprains

Grade I: ice, elevation, NSAIDs, ankle brace, weight bearing may begin immediately. D/C brace in 1 month. Grade II: ice, elevation, NSAIDs, ankle brace, no weight bearing x 7 days Grade III: walking cast x 3 4 weeks, PT, ankle brace
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY, NY: The McGraw-Hill Companies.
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Differentiation between various grades

First degree: minimal pain, joint stable Second degree: severe pain, minimal joint instability Third degree: severe pain and complete instability
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY, NY: The McGraw-Hill Companies. PIHE 2012
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Fractures
Most common in children:
Fingers, toes, distal radius, clavicle, ankle
Chondromalacia Patella
Occurs mainly in adults but can occur in adolescents Pain occurs when climbing stairs or going from a squatting position to standing Diagnosis: Consider knee films to r/o subluxation of the patella
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Assessment
Capillary refill Surrounding skin Sensation
Treatment
Stabilization, elevation, ice Casting
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Treatment of Chondromalacia Patella

Decrease activities which require full flexion of the knee and stress on the patellofemoral joint RICE Quad muscle strengthening Physical therapy may be helpful Consider orthotics if needed NSAIDs as needed
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Osgood Schlatter Disease

Most common in later childhood and early adolescence Painful swelling and tenderness of the tibial tuberosity Increases with resisting knee extension Treatment:
Decrease quad loading and bending RICE treatment protocol Quad and hamstring stretching NSAID as needed PIHE 2012
Headache
Neurologic Conditions
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Headaches are common in childhood and adolescence Primary headaches account for 90+% of all headaches:
Migraine Tension Cluster
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Headache
Indications for Headache Work-up
Systemic symptoms Neurologic signs and symptoms Onset Onset (< 5 or > 50) Previous headache
PIHE 2012 Dodick DW. Adv Stud Med. 2003;3:87-92.
Treatment for Headaches

Tension:
NSAID or acetaminophen Rest and heat
Migraine
NSAID or acetaminophen Trigger Avoidance Triptan Preventative therapies, as indicated
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Syncope
Syncope: sudden loss of consciousness with spontaneous recovery Majority of syncopal episodes in children are benign however, must consider the following
Seizure activity Cardiac malformations/pathology
Syncope
accessed 08-22-2008 http://www.aafp.org/afp/20050601/tips/13.html PIHE 2012
http://www.aafp.org/afp/20050601/tips/13.html accessed 08-22-2008 PIHE 2012
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 Minimal
Concussion
Classification of Head Injuries
No LOC + additional symptoms
Mild
LOC < 5 minutes + additional symptoms
Moderate or Severe
LOC > 5 minutes + additional symptoms
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Second Impact Syndrome

Suffers second head injury without having fully recovered from first May lead to severe intracranial swelling and death
Return to Play
Multiple Grade 1 1 week Grade 2 1 week Multiple Grade 2 2 weeks Grade 3 1 2 weeks Multiple Grade 3 1 month or greater Remind player of preventive activities
Helmets
American Academy of Neurology, Quality Standards Subcommittee: Practice Parameter. (1997)). The management of concussion in sports, Neurology, 48, 581PIHE 2012 87.
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Concussion
Dermatologic Conditions
http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm PIHE 2012 accessed 07-12-2008
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Abscess
Definition:
Collection of pus in the cutaneous tissue which results in a painful, erythematous, fluctuant mass
Cutaneous Abscesses
Pathogens
Methicillin sensitive staphylococcus aureus Methicillin resistant staphylococcus aureus
Treatment
Incision and drainage is the treatment of choice Many recommend wound culture Antibiotics may be utilized but are not as effective as I&D Warm soaks/compresses
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Most common locations

Inguinal region, neck or back, axillary region, vaginal
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Verruca Vulgaris
Common warts Benign lesions of the epidermis caused by a virus Transmitted by touch and commonly appear at sites of trauma, on the hands, around the periungual regions from nail biting and on the plantar surfaces of the feet
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Verruca Vulgaris
Appearance
Smooth, flesh colored papules which evolve into a dome-shaped growth with black dots on the surface Black dots are thrombosed capillaries and can be visualized with a 15 blade
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Verruca Vulgaris
Treatment

Verruca Vulgaris
OTC product: Compound W or similar OTC cryosurgery kit Liquid nitrogen Duct tape Cryosurgery in office Cimetidine Immunomodulatory effects at high dosages; effects varied Imiquimod Retin A type products Electrocautery Blunt dissection (plantar lesions)
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Urticaria
Etiology
Referred to as wheals or hives Causes: Foods, soaps, inhaled substances 20% of the population will have at least one episode 2 types: Acute and Chronic
Acute is most common - lasting days to weeks (Cause is most often identified) Chronic: Lasts more than 6 weeks (Cause is rarely identified)
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Urticaria
Symptoms
Hives itch!!!!! Red plaques
Signs
Red lesions which vary in size from 2 - 4 mm Blanche with palpation
Diagnosis
History and physical examination
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Urticaria
Plan
Therapeutic
Urticaria
Stop medications if possible Stop suspected foods or drinks Cool compresses Antihistamines/H2RA Prednisone
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Urticaria Plan
Educational
Avoid causes Educate regarding possible etiology Discuss side effects of antihistamines (sedation)
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Impetigo
Contagious, superficial skin infection Caused by staphylococci or streptococci
Staph is the most common cause Makes entrance through small cut or abrasion Resides frequently in the nasopharynx
Spread by contact More common in children, particularly on the nose, mouth, limbs
Self-limiting but if untreated may last weeks to PIHE 2012 months
Impetigo
Symptoms:
Rash that will not go away Begins as a small area and then increases in size Yellow, crusted draining lesions
Impetigo
Physical Examination Findings

Small vesicle that erupts and becomes yellowbrown Initially, looks like an inner tube Crust appears and if removed, is bright red and PIHE 2012 inflamed
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Impetigo
2-8 cm in size
Impetigo
Educational
Good handwashing and hygiene No school/daycare for 24 - 48 hours Wash sheets and pillowcases Monitor for serious sequelae
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Diagnosis
Diagnostic:
Culture Today, must absolutely consider MRSA
Therapeutic:
Bactroban vs. Altabax 1st generation cephalosporin vs. PIHE 2012 TMP/SMX
CA- MRSA
CA - MRSA
First identified in the 1940s; first US case 1968

CA-MRSA is distinctly different than the MRSA identified in hospitals Most CA-MRSA are known as USA300 or USA400 whereas hospital infections are USA100, USA500
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Since 1990, the burden on society has increased substantially Most infections are located in the soft tissue and present as carbuncles, furuncles or Wright, 2012 abscesses
CA-MRSA
First domestic cluster of cases identified in 1982 in Detroit, Michigan
IV drug users
CA-MRSA
1992, 2nd cluster among IV drug users
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CA-MRSA
Males are affected more often than females Affects the very young and old disproportionately Blacks are also affected at greater rates than whites Recurrent antimicrobial usage may be a risk factor Exposure to farm animals and even household petsWright, 2012
CA-MRSA
Current estimates:
25 30% of people carry colonies of staphylococci in their noses < 2% are colonized with MRSA
Wright, 2012
CA-MRSA
Most CA-MRSA infections are not usually severe or associated with deaths although the CA strains are believed to be more virulent than the hospital strains However, current yearly estimates are:
95K invasive infections 19K deaths
CA - MRSA
mecA gene
This is where the resistance originates with MRSA PCN cant bind at its target
A lot of cross resistance to beta lactam antibiotics: PCN and cephalosporins particularly in the USA300 strain which is the CA-MRSA strain
Wright, 2012
Wright, 2012
CA-MRSA
2002 handful of cases of the bacterium which is resistant to vancomycin
No significant risk factors for adverse outcomes I&D is the treatment of choice; antibiotics may not be necessary For those in whom antibiotics should be considered:
Significant pain Cellulitis Rapid progression Immunosuppression Wright, 2012 Comorbidities
Treatment for Uncomplicated CA-MRSA
Wright, 2012
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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
Treatment of CA-MRSA
Obtain culture Should consider local antibiograms in selection of antimicrobials Skin infections:
Consider beta-lactam (PCN or Cephalo) in an individual with mild infection and low rates of CAMRSA in your community (generally thought of as < 10 15%)
Guilbeau, J.R. and Fordham, P.N. Evidence-Based management and Treatment of Outpatient Community-Associated MRSA. The Journal for Nurse Practitioners. 2010; Vol 6(2):140-145
Bactrim has best coverage/sensitivity: 9698%

Important for clinicians to obtain own antibiogram for communities in which you service
Wright, 2012
Wright, 2012
Treatment of CA-MRSA
Skin infections:
TMP/SMX Clindamycin (Monitor closely for resistance; D-Zone test) Tetracyclines (avoid under 8 years of age) Rifampin add on to other agents Linezolid Avoid fluoroquinolones (increasing resistance)
Treatment and Eradication Strategies: Recurrent infections

GOOD handwashing Treatment with Bactrim,clinda, TCN, Linezolid
Consider addition of rifampin
Bathe with disinfectants

Hibiclens, phisodex, clorox bleach
Utilize topical disinfectants

Purell Mupirocin seeing resistance
Wright, 2012
Wright, 2012
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 days along with daily cholorhexidine 4% bath. Alternative
Doxycycline 100 mg bid or TMP/SMX DS + rifampin 300 mg every 12 hours x 5 days
Another Option
Mupirocin nasal ointment plus bleach baths (one tablespoon of bleach in 1 quart of water)
Able to decolonize the skin
Some strains of MRSA (USA300 MRSA clones) are resistant to mupirocin
Wright, 2012
Wright, 2012
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More Natural Options

Stay tuned
Lemongrass essential oil has been shown to inhibit all MRSA colony growth Tea tree oil has also been shown effective French clay is also being studied
Additional Considerations
CA - MRSA
Can colonize in animals; household pets Consider animal treatment with recurrent disease
Fomites
May be a source of CA - MRSA Can live > 5 weeks on vinyl or block toys Can live on towels for 7 10 days
Wright, 2012
Wright, 2012
Who Should Be Hospitalized?

Two or more of the following:
Fever > 100.4 Wbc count: > 13,000/uL Bands > 10% Hand cellulitis Facial cellulitis Immunocompromise Failing outpatient therapy Age > 70 years of age
Wright, 2012
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
PIHE 2012
This is NOT a Lyme Bearing Tick
Lyme Bearing Tick
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PIHE 2012
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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 PIHE 2012

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
PIHE 2012
Summer 2009
Erythema Migrans
PIHE 2012
PIHE 2012
Erythema Migrans

Signs
Systemic symptoms: Stage 3 Facial palsy Meningitis Carditis
Diagnosis
R/O Ringworm (Tinea Corporis)
PIHE 2012
PIHE 2012
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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
PIHE 2012

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
PIHE 2012
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 PIHE 2012 Symptoms

Pityriasis Rosea
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
PIHE 2012
Pityriasis Rosea
Signs
Pityriasis Rosea
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
PIHE 2012
PIHE 2012
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Pityriasis Rosea
Signs (continued) 7-14 days after the herald patch Lesions are on the trunk and proximal extremities Can also be on the face
Pityriasis Rosea
Diagnosis
Plan
Diagnostic Can do a punch biopsy if etiology uncertain
Pathology is often nondiagnostic Report: spongiosis and perivascular round cell infiltrate
PIHE 2012
Consider an RPR to rule-out syphilis

PIHE 2012
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
PIHE 2012
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
PIHE 2012
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
PIHE 2012
PIHE 2012
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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 PIHE 2012 TCA
Plan
Educational May resolve on own in 6 - 9 months Contagious until lesions are gone Benign Recurrence very common
PIHE 2012
Scabies Etiology
Contagious disease caused by a mite Common among school children Adult mite is 1/3 mm long Front two pairs of legs bear clawshaped suckers
PIHE 2012
Scabies
Etiology
Infestation begins when a female mite arrives on the skin surface Within an hour, it burrows into the stratum corneum
Lives for 30 days Eggs are laid at the rate of 2-3 each day Fecal pellets are deposited in the burrow behind the advancing female mite (Scybala)-feces are dark oval masses that are irritating and often responsible for itching
PIHE 2012
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
PIHE 2012
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
PIHE 2012
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Scabies
Scabies
PIHE 2012
PIHE 2012
Scabies
Diagnosis
Scraping to look for mite, eggs or feces
Plan
Scabies
Plan
Diagnostic: Scraping Therapeutic Permethrin 5% cream
PIHE 2012
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
PIHE 2012
Scabies
Plan
Educational Wash all clothing, towels and bed linen Do not need to wash carpeting Consider animal bathing Bag stuffed animals x 1-2 weeks
PIHE 2012
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
PIHE 2012
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Treatment
Treat hair with pediculicide and comb nits daily Machine wash all in hot water cycle (130 degrees F or dry clean items Put items which cant be cleaned into a plastic bag and seal it for two weeks Soak combs and brushes for one hour in rubbing alcohol or Lysol Vacuum the floor and furniture
PIHE 2012
Newer Treatment Options

Spinosad (Natroba)
New option for head lice
$220.00 for this product Indicated for 4 years of age and up
Ivermectin (SKLICE)
PIHE 2012
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
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
PIHE 2012
PIHE 2012
Atopic Dermatitis
Etiology
Etiology
High levels of serum IgE are common
Higher the levels of IgE-more severe the case
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
PIHE 2012
Proliferation of T-helper 2 cells; Th-2 cells produce cytokines Cytokines cause an inflammatory response in the skin
PIHE 2012
PIHE, 2012
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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)
Diagnosis?
PIHE 2012
PIHE 2012
Common Locations
Atopic Dermatitis
Plan
Diagnostic
None
Infants: scalp, face, and extensors Children: neck, flexor folds, feet
Therapeutic
Lubrication: Most important part Perform multiple times daily; particularly after a bath
PIHE 2012
PIHE 2012
Atopic Dermatitis
Therapeutic
Limit number of baths or showers
Avoid harsh soaps
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
Antihistamines: OTC or prescription Low potency topical corticosteroids Immunomodulator (Elidel or Protopic) Avoids soaps, bath gels, bubble baths, shower gels Intralesional injections of corticosteroids Oral corticosteroids
PIHE 2012
PIHE 2012
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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
PIHE 2012
Diagnosis?
PIHE 2012
Acne Vulgaris
Diagnosis
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
PIHE 2012
Plan
Diagnostic: None Therapeutic
Benzoyl Peroxide: papules Topical Antibiotics: inflammatory lesions Oral Antibiotics: inflammatory lesions Tretinoin: scarring, inflammatory lesions OCPs PIHE 2012 Accutane: cystic acne
Tinea Corporis
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
PIHE 2012
PIHE 2012
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Human Herpes Virus

HHV 1 and 2 Spread in 3 manners
Respiratory droplets Contact with an active lesion Contact with fluid such as saliva
Herpes Simplex Virus

Symptoms Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling
90% of primary infections are asymptomatic Symptoms usually occur 3 - 7 days after contact
PIHE 2012
PIHE 2012

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
PIHE 2012
PIHE 2012
Herpetic Gingivostomatitis
Plan

Diagnostic Viral Culture HSV IgG & IgM serum antibodies Most accurate: HerpeSelect Therapeutic Antiviral Pain reliever Cool rinses Oragel PIHE 2012
PIHE 2012
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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)
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
PIHE 2012 http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010
PIHE 2012
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
PIHE 2012 accessed 03-01-2010 http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm
Roseola
Treatment
Ibuprofen Acetaminophen Tepid baths
Cautiously with fever
PIHE 2012 http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010
Fifths Disease (Erythema Infectiosum)

Human Parvovirus B19
Occurs in epidemics Occurs year round: Peak incidence is late winter and early spring

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
PIHE 2012
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 PIHE 2012 are immunocompromised
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Low grade temperature Erythematous cheeks
Nontender and well-defined borders
Fifths Disease
Netlike rash
Erythematous lesions with peripheral white rims Rash-remits and recurs over 2 week period
Petecchiae on hands and feet PIHE 2012
PIHE 2012
Fifths Disease

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
PIHE 2012
PIHE 2012

Diagnosis/Plan
Was contagious before rash appeared therefore, no isolation needed
Spread via respiratory droplets
Hand, Foot, and Mouth Disease (Coxsackie Virus)

Caused by the coxsackie virus A16 or 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 2012 20% of children willPIHE experience lymphadenopathy
Symptomatic treatment Patient education-I.e. contagion, handwashing Can cause aplastic crisis in individuals with hemolytic anemias Concern regarding: miscarriage, fetal hydrops Adults: arthralgias
PIHE 2012
PIHE, 2012
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Oral lesions are usually the first to appear
90% will have

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
PIHE 2012
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 PIHE 2012
Hand Foot and Mouth Disease
Hand Foot and Mouth Disease
PIHE 2012
PIHE 2012

Plan
Diagnostic: None Therapeutic
Tylenol Warm baths Oragel or Benadryl/Maalox Magic mouthwash
PIHE 2012

Plan
Educational
Very contagious (2d before -2 days after eruption begins) Entire illness usually lasts from 2 days 1 week Reassurance No scarring
PIHE 2012
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Kawasaki Disease
Characterized by an systemic vasculitis throughout the body Seventy five percent of patients are under five years old It is more common in boys than girls Majority of cases occur in the winter and early spring Believed to be viral in etiology and is not contagious
PIHE 2012
Kawasaki Disease
Diagnosis is based on clinical criteria by the American Heart Association:
fever for 5 or more days (102 104) a polymorphous exanthem nonpurulent conjunctivitis changes in the mucosa of the lips / oral cavity redness or edema with later desquamation of the extremities at least one cervical lymph node > 1.5 cm in diameter
PIHE 2012 http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010
http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010
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
PIHE 2012 accessed 03-01-2010 http://circ.ahajournals.org/cgi/content/full/110/17/2747
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PIHE 2012
PIHE, 2012
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Another Great Resource for Pediatrics

PIHE 2012 www.brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 03-1022012011

Development & Anticipatory Guidance Anticipatory Guidance

Car Seat Recommendations

Eye Examinations and Vision

USPSTF Hearing Screening Recommendations

Development & Anticipatory Guidance

Identify those infants and children with developmental disorders

M-CHAT Screening Tool

Look for the Presence of Red Flags

Continued risk factor assessment throughout childhood

http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sche d%20101107.pdf accessed 03-10-2011

Continued risk assessment throughout childhood

http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%2 0Sched%20101107.pdf accessed 03-10-2011

http://www.aap.org/obesity/USPSTF.html accessed 03-10-2012

What To Do With Children

What To Do With Children

http://www.aap.org/obesity/USPSTF.html accessed 03-10-2012

Diabetes: Screening in Children

What Constitutes a Risk Factor in Children?

Male normal onset:

General Health Counseling

General Health Counseling

Immunization schedule: aged 0 through 6 years United States, 2012

Immunization schedule: aged 7 through 18 yearsUnited States, 2012

ACIP Recommendations for Use of Meningococcal Conjugate Vaccine in Adolescents

ACIP Guidance on Meningococcal Vaccines and College Enrollment1

Reference: 1. CDC. MMWR. 2011;60(3):72-76.

References: 1. CDC. MMWR. 2011;60(3):72-76. 2. CDC. MMWR. 2007;56(41):794-795.

ACIP Recommendations for Meningococcal Conjugate Vaccination of Infants1

Persons infected with human immunodeficiency virus (HIV)

The recommendation is for 2 doses, given 3 months apart

Does not include infants with functional or anatomic asplenia.

Reference: 1. CDC. MMWR. 2011;60(3):72-76.

.5 ml injection IM injection into deltoid

Additional Indication for HPV4

Additional HPV2 Vaccine

When child presents with a fever of 5 7 days or less, must consider:

Worrisome Findings: Consider Hospitalization

Caution regarding cool sponge baths Education:

Document visual acuity on all eye complaints

Seasonal is most common and caused by the following triggers

Moderate conjunctival injection Unilateral at onset

Signs and Symptoms

Variations of Tympanic Membrane Normal TM

Acute Otitis Media

Identify signs of middle ear inflammation

Criteria for Initial Treatment or Observation in AOM

Criteria for Initial Treatment or Observation in AOM

Antibacterial therapy if severe illness; observation option if nonsevere illness

Antibacterial Agents in AOM

Recommended Antibacterial Agents in AOM

NonNon -Type I: Cefdinir, Cefuroxime, or Cefpodoxime Type I: Azithromycin, Clarithromycin Ceftriaxone

NonNon -Type I: Ceftriaxone

Type I: Clindamycin Tympanocentesis, Tympanocentesis , clindamycin

Duration of Treatment for AOM

Otitis Media with Effusion

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

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

If respiratory distress is severe, do not examine the pharynx

ENT consult is essential Usual management

Viral Upper Respiratory Infection

Consider the following: