pediatric refresher 2016 08-15-2016 -...
TRANSCRIPT
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This program was developed by Wendy L. Wright APRN and accredited by Partners in Healthcare Education, an provider of nurse practitioner continuing education by the
American Association of Nurse Practitioners; provider number 031206.This program is sponsored through a restricted educational grant from Walgreens.
Evidence Based Pediatric Treatment Guidelines 2016
Clinical Practice Strategies for the Retail Clinician
Wendy L. Wright, MS, RN, APRN, FNP, FAANP, FAANOwner – Wright & Associates Family Healthcare
Owner – Partners in Healthcare Education
Wright, 2016
Another Great Resource for Pediatrics
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https://www.aap.org/en-us/Documents/periodicity_schedule.pdf accessed 08-15-2016
Development & Anticipatory Guidance
• Developmental Screening– 9 months
– 18 months
– 30 months
• Identify those infants and children with developmental disorders
3Wright, 2016
https://www.aap.org/en-us/Documents/periodicity_schedule.pdf accessed 08-15-2016
Development & Anticipatory Guidance
• Anticipatory Guidance–Every visit from birth – age 21
–Specific guidance is based upon age
4Wright, 2016
https://www.aap.org/en-us/Documents/periodicity_schedule.pdf accessed 08-15-2016
Eye Examinations and Vision
• AAP recommendations– Begin vision screening as a newborn
– Formal screening at:• Age 3 years
• Age 4 years
• Age 5 years
• Age 6 years
• Age 8, 10, and 12 years
• Age 15 and 18 years
5Wright, 2016
AAP Updates
• Hearing Screening– Most common congenital developmental
abnormality affecting children in the United States
– Screen before 1 month
– Repeat by 3 months if abnormal
– If abnormal, referred to early intervention before age 6 months for formal evaluation
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https://pediatriccare.solutions.aap.org/DocumentLibrary/Periodicity%20Schedule_FINAL.pdfaccessed 06-10-2015
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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 well-
child visits
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https://www.aap.org/en-us/Documents/periodicity_schedule.pdf accessed 08-15-2016
USPSTF Hearing Screening Recommendations
• The USPSTF recommends screening for hearing loss in all newborn infants
• All infants should have hearing screening before 1 month of age
• Those infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 months of age for confirmatory testing– These children should undergo periodic monitoring
for 3 years
8Wright, 2016
http://www.guidelines.gov/content.aspx?id=12640&search=hearing accessed 05-01-2014
Dental Examination
• AAP recommendations– Begin at age 12 months
– 18 months
– 24 months
– 30 months
– 3 years of age
– 6 years of age
9Wright, 2016
Autism Screening
• Universal screening– Formal ASD screening on all children at 18 and 24
months regardless of whether there are any concerns
– Guidelines stress that providers need to ask/discuss any concerns that parents may have at every well-child visit
10Wright, 2016
http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011
M-CHAT Screening Tool
• Conducted at 18 and 24 months
• Can learn to become certified autism screener
• https://m-chat.org/
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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.
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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
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http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 05-01-2014
Anemia Screening
• AAP recommendations– Age 12 months
– Hemoglobin or hematocrit
• Continued risk assessment throughout childhood
14Wright, 2016
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 05-01-2014
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Children and Diabetes Screening• Begin at 10 years of age in children
at risk or at the onset of puberty, if earlier than 10 years–Repeat every 3 years, if normal
www.diabetes.orgwww.aace.com
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What Constitutes a Risk Factor in Children?
• Overweight (BMI>85th %tile for age and sex, weight for height >85th%tile, or weight >120% of ideal for height)
• In addition – presence of two or more of the following:
– Family history of type 2 diabetes in first- or second-degree relative
– Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)
– Signs of, or conditions associated with, insulin resistance including acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, small for gestational age at birth history in the child
– Maternal history of DM or gestational DM
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http://care.diabetesjournals.org/content/36/Supplement_1/S11.full accessed 05-20-2014
General Health Counseling
• Seatbelts
• Helmets
• Sunscreen
• Smoke Detectors
• Pool Safety
• Carbon Monoxide
• Guns
• Domestic Violence17Wright, 2016
General Health Counseling
• Drugs
• Alcohol
• Smoking
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Remember –School / sport physicals may be the only contact that the child has with a health
care professional in a yearWright, 2016
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Depression Screening
• AAP recommends depression screening for all adolescents11-21 years of age
• Validated depression screening tool recommended– PHQ-2 or PHQ-9
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https://www.aap.org/en-us/Documents/periodicity_schedule.pdf accessed 08-15-2016
Vaccine Updates 2016
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ACIP Recommendations –October 2010
• ACIP recommends routine vaccination of adolescents with MCV4 beginning at age 11 through 12 years at the pre-adolescent vaccination visit, with a booster dose at age 16 years.
• For adolescents vaccinated at age 13 through 15 years, a one-time booster dose should be given 3 to 5 years after the first dose.
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Updated ACIP Recommendations
Why Change the Program Now?
• Data indicates protection wanes within 5 years after vaccination
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HPV 9• Recently approved
• 5 additional strains of protection– Will provide an additional 20% reduction in
cervical cancer
• Approved: – Same approvals as HPV4
• Now available
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Approved
• Neisseria meningitidis Group B
• Indications:– Age 10 – 25 years of age
– Trumemba: Three doses:• Day 0, day 2 months and day 6 months
– Bexsero: Two doses• Day 0 and day 1 month
• Indications: – Outbreaks
– Immunocompromised
– Asplenic
– Cochlear implants
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Influenza
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Important Influenza Messages
• Begin to vaccinate as soon as flu vaccines are received in clinics
• Immunity lasts throughout entire flu season, even if vaccines are given in August
• All healthcare professionals who care for patients in a protected environment (severely immunocompromised) should receive the Trivalent Inactivated Vaccine (TIV) rather than LAIV
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2016 – 2017 Flu vaccine
• A/California/7/2009 (H1N1)pdm09-like virus,
• A/Hong Kong/4801/2014 (H3N2)-like virus,
• B/Brisbane/60/2008-like virus (B/Victoria lineage), and
• B/Phuket/3073/2013-like virus (B/Yamagata lineage) for the quadrivalent vaccine
Wright, 2016
http://www.consultant360.com/exclusives/fda-2016-2017-flu-vaccines-approved accessed 06-25-2016
2016: LAIV update
• No longer recommended based upon efficacy
• That data showed the estimate for LAIV among study participants 6 months – 17 years group against any flu virus was 3 percent
• QIV: 63% efficacy overall
Wright, 2016
http://www.cdc.gov/media/releases/2016/s0622-laiv-flu.html accessed 06-25-2016
Egg Allergy and TIV• 2011 - The recommendation is as follows:
– For patients with a history of egg allergy WITHOUT anaphylaxis, there is no need to divide doses or perform skin testing before vaccination
– There will be no need to confirm the levels of ovalbumin in the 2011-12 flu vaccine because all products will contain less than 0.6 micrograms per dose;
– Patients with egg allergy should be observed for 30 minutes after vaccination; and
– Vaccine providers should be equipped and trained to handle anaphylactic emergencies
– Do not use LAIV (Flumist)Wright, 2016 30
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MMR and Travel• Before departure, children aged 6–11
months should receive the first dose of MMR vaccine– Infants vaccinated before age 12 months must
be revaccinated on or after their first birthday with 2 doses of MMR vaccine, separated by at least 28 days
Wright, 2016 31http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/vaccine-recommendations-for-infants-and-children.html accessed 12-30-2012
General
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Management of Fever• Definition
– Temperature > 37.2° C orally or > 98.9° F in am
– OR….> 37.7° C orally or > 99.9° F in afternoon – pm
• When child presents with a fever of 5 – 7 days or less, must consider:– Viral vs. Bacterial infections
– Bacteremia
– Sepsis33Wright, 2016
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 tone34Wright, 2016
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 comfortable35Wright, 2016
Management of Fever• Options for treatment (weight/age dosing)
– Acetaminophen
– Ibuprofen
• Caution regarding cool sponge baths
• Education:– Monitor closely
– Reinforce when to call or return
– Avoid aspirin and related products
– Increase fluids36Wright, 2016
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Eyes
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Clinical Pearl:
Document visual acuity on all eye
complaints
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Hordeolum
• Etiology– Obstruction of the glands of Zeiss
– Staphylococcal aureus is the most common causative organism
• History– Swollen, red, painful lesion on the lid margin
– Itchiness of the eyelid
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Hordeolum
• Physical examination– Erythematous, tender nodule on the margin of the
eyelid
– Surrounding edema
• Treatment– Warm compresses-20 minutes qid
– Antimicrobial ointment or drops
– Good eye hygiene and handwashing
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Hordeolum
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Internal Hordeola
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Viral Conjunctivitis• Etiology
– Adenovirus is the most common cause• 40 strains identified
– Recent studies have shown that it can remain viable on plastic and metal surfaces for up to 1 month
• Symptoms– Watery discharge, foreign body sensation, redness
– URI symptoms are common including sore throat and fever
– Often bilateral43Wright, 2016
Viral Conjunctivitis
• Signs– Normal visual acuity, PERRLA, EOMI, Fund nl
– Mucoid-slightly watery discharge
– Mild, diffuse injection
– Preauricular lymphadenopathy
• Treatment– Symptomatic only
– Cool compresses
– Strict eye hygiene44Wright, 2016
Viral Conjunctivitis
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Bacterial Conjunctivitis
• Etiology– Staphylococcus aureus
– Streptococcus pneumoniae/pyogenes
– Haemophilus influenzae
– Neisseria gonorrhea
• Symptoms– Redness, swelling, purulent discharge, itching
– No symptoms until eye complaints began
46Wright, 2016
Bacterial Conjunctivitis• Signs
– Normal visual acuity, PERRLA, EOMI, Fund nl
– Diffuse injection
– No ciliary injection
– Unilateral at onset
• Treatment– Topical antimicrobials x 5-7 days
– Warm compresses qid x 10-20 minutes
– Strict eye hygiene given contagion47Wright, 2016
Bacterial Conjunctivitis
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Conjunctivitis
• Bacterial– Non-palpable nodes
• GC and Chlamydia +
– Purulent discharge• GC-Mucopurulent
– Moderate conjunctival injection
– Unilateral at onset
• Viral– Palpable preauricular
node
– Watery discharge
– Mild-moderate conjuctival injection
– URI symptoms
– Bilateral
49Wright, 2016
Allergic Conjunctivitis• Two types of allergic conjunctivitis
– Seasonal and perennial
• Seasonal is most common and caused by the following triggers– Pollens
– Grass
– Ragweed
• Perennial persists all year and is caused by indoor allergens, such as dust mites
50Wright, 2016
Signs and Symptoms
• Symptoms– Itching
– Watery– stringy-like clear discharge
• Signs– Injected conjunctiva
– Other physical examination findings such as:• Dennie’s lines
• Allergic shiners
• Allergic facies
• Allergic crease 51Wright, 2016 52Wright, 2016
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Treatment
• Systemic and/or topical antihistamines relieve acute symptoms due to interaction of histamine at ocular H1 and H2 receptors
• Examples of topical antihistamines include: epinastine (Elestat) and azelastine (Optivar)
• Vasoconstrictors are available either alone or in conjunction with antihistamines to provide short-term relief of vascular injection and redness• Common vasoconstrictors include naphazoline,
phenylephrine, oxymetazoline, and tetrahydrozoline
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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)
55Wright, 2016
Emergency: Ophthalmologic Triad
• Pain
• Red eye
• Vision changes
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Case Study 3: TYTY is a 5 yowm who presents with his mom for an
evaluation of (R) pink eye. Began this am. Denies discharge, itching, recent URI. Mom denies trauma but does report strange occurrence yesterday. He failed to respond to her calling. When he finally came, he reported being asleep outside.
PE: Absent red reflex-OD; Visual acuity 20/100 (OD); 20/30 (OS); Pupil-slightly constricted (OD). Unable to view the fundus (OD)
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Hyphema• Definition
– Bleeding into the anterior chamber of the iris
– Causes include trauma or surgery
• Symptoms– Pain, red eye, blood in anterior chamber
– Blurred or Absent vision
• Signs– Absence of the red reflex
– Blood in the anterior chamber
– Increased IOP
Wright, 2016http://www.ncbi.nlm.nih.gov/pubmed/1788129 accessed 06-01-2012 58
Hyphema
• Signs– Decreased visual acuity
– Injected conjunctiva (mild-severe)
Wright, 2016http://www.ncbi.nlm.nih.gov/pubmed/1788129 accessed 06-01-2012 59
Hyphema
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Complication of Hyphema
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Hyphema
• Treatment– Always assume that the globe is ruptured as 25%
have other serious ocular injuries
– Shield the eye and refer immediately
– Can lead to devastating visual complications including blood staining of the cornea, glaucoma, atrophy of the optic nerve
Wright, 2016http://www.ncbi.nlm.nih.gov/pubmed/1788129 accessed 06-01-2012 62
Herpes Simplex
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Corneal Ulcer
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Nose/Sinuses
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IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis
in Children and AdultsClinical Infectious Diseases Advance
Access published March 20, 2012
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http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
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Algorithm for the management of acute bacterial rhinosinusitis
Chow A W et al. Clin Infect Dis. 2012;cid.cir1043
© The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected].
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What Constitutes at Risk for Resistance?
• Age < 2 years or > 65 years
• Daycare
• Antimicrobial within past 1 month
• Hospitalization within past 5 days
• Comorbidities
• Immunocompromised
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http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
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Goals of Treatment
• Restore integrity and function of ostiomeatal complex– Reduce inflammation
– Restore drainage
– Eradicate bacterial infection
http://www.medscape.com/viewprogram/5621 accessed 01-22-07
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Treatment of Acute Bacterial Rhinosinusitis
• Nonpharmacologic Therapies– Cold steam vaporizer
– Increased water intake
– Intranasal saline irrigations with either physiologic or hypertonic saline are recommended as an adjunctive treatment in adults with ABRS1
1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
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Management Strategies in ABRS
• Antihistamines or decongestants– No longer recommended
• Topical corticosteroids– Intranasal corticosteroids are recommended as an adjunct to
antibiotics in the empiric treatment of ABRS, primarily in patients with a history of allergic rhinitis1
• Corticosteroids
1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
Antimicrobial Regimens in Children
Wright, 2016 72http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlaccessed 12-29-2012
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Important Changes
• Macrolides (clarithromycin and azithromycin) are not recommended due to high rates of resistance among S. pneumoniae (30%)
• TMP/SMX is not recommended due to high rates of resistance among both S. pneumoniae and H. influenzae (30%–40%)
• Second and third-generation cephalosporins are no longer recommended due to variable rates of resistance among S. pneumoniae.
Wright, 2016 73
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlaccessed 12-29-2012
Length of treatment
• The recommended duration of therapy for uncomplicated ABRS in adults is 5–7 days
• In children with ABRS, the longer treatment duration of 10–14 days is still recommended
Wright, 2016 74
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
When to Change Treatments
• An alternative treatment should be considered if symptoms worsen after 48–72 hours of initial empiric antimicrobial therapy, or when the individual fails to improve despite 3–5 days of antimicrobial therapy
Wright, 2016 75
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
When to Refer
Wright, 2016 76http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
Ear Conditions
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Variations of Tympanic MembraneNormal TM
Acute OM
Otitis Media with Effusion
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AAP Updated Guidelines• Diagnosis of AOM:
– Evidence: 1A• Moderate - severe bulging of TM
• OR…new otorrhea NOT due to otitis externa
– Evidence: 1B• Mild bulging of TM and….
– Recent ( < 48 hours) onset of ear pain or….
• Intense erythema of TM
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http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
AAP Updated Guidelines (cont.)• Severe AOM:
– Prescribe antimicrobial for AOM in children 6 months or older with severe signs and symptoms
• Moderate or severe otalgia for at least 48 hours OR…
• Temperature: 102.2 (39 degrees Celsius)
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http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
AAP Updated Guidelines (cont.)• Nonsevere bilateral AOM in children < 24
months without signs or symptoms:– Antibiotics should be prescribed even in the
setting of mild symptoms• Mild otalgia < 48 hours
• Temperature < 39 degrees Celsius
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http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
AAP Updated Guidelines (cont.)• Nonsevere unilateral AOM in children age 6
month – 23 months:– Two options:
• Antimicrobial therapy
• Observation as treatment option– Nonsevere
– Follow-up must be ensured
– Start antimicrobials if worsen or no improvement with 48 – 72 hours
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http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
AAP Updated Guidelines (cont.)• Nonsevere AOM in older children (24 months
or older):– Two options:
• Antimicrobial therapy
• Observation as treatment option– Nonsevere
– Follow-up must be ensured
– Start antimicrobials if worsen or no improvement with 48 – 72 hours
Wright, 2016 84
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
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Summary: AAP Updated Guidelines (cont.)
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http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
AGE Otorrhea with AOM
Unilateral or Bilateral AOM
with Severe Symptoms
Bilateral AOM without
Otorrhea
Unilateral AOM without
Otorrhea
6 months – 2 years Antibiotic Antibiotic Antibiotic Antibiotictherapy or
observation
> 2 years Antibiotic Antibiotic Antibiotic or observation
Antibiotic or observation
AAP Updated Guidelines (cont.)• Treatment options:
– Amoxicillin: first line• Provided that: no antibiotics in previous 30 days and
• No purulent conjunctivitis and
• Not allergic to PCN
Wright, 2016 86
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
AAP Updated Guidelines (cont.)• Treatment options:
– Amoxicillin/clavulanate• Child who has received antibiotics in previous 30 days
OR….
• Has concurrent purulent conjunctivitis OR….
• History of AOM which is unresponsive to amoxicillin
Wright, 2016 87
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
Initial Immediate or Delayed Antibiotic Treatment
Recommended First line Treatment Alternative Treatment (if Penicillin Allergy)
Amoxicillin (80-90 mg/kg/day) in two divided doses OR
Cefdinir (14 mg/kg/day) in one – two divided doses
Cefuroxime (30 mg/kg/day) in two divided doses
Amoxicillin/clavulanate (90 mg/kg/day or amoxicillin) with 6.4 mg/kg/day of clavulanate) in two divided doses
Cefpodoxime (10mg/kg/day) in two divided doses
Ceftriaxone (50 mg IM or IV) daily for 1 or 3 days
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http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
Antibiotic Treatment After 48-72 hours of Failure of Initial Antibiotic
Recommended First line Treatment Alternative Treatment (if Penicillin Allergy)
Amoxicillin/clavulanate (90 mg/kg/day or amoxicillin) with 6.4 mg/kg/day of clavulanate) in two divided doses
Ceftriaxone 3 dayClindamycin (30 – 40 mg/kg/day) in three divided doses with or without concomitant
third generation cephalosporin
Ceftriaxone (50 mg IM or IV) for 3 days Clindamycin (30 – 40 mg/kg/day) in three divided doses with concomitant third
generation cephalosporinTympanocentesisConsult specialist
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http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
Remember…
• For children with OM and tympanostomy tubes:– You may also utilize topical medications
– Ofloxacin (Floxin Otic) 0.3% solution• Age 1 - 12 years: 5 drops into affected ear bid x 10
days
– Ciprofloxacin (Ciprodex): • 6 months and up: 4 drops into the affected ear bid x 7
days
90Wright, 2016
16
Duration of Treatment for AOM
• Results– 10 days: Patients <2 years old or those with
severe symptoms– 7 days: Age 2-5 years of age with mild – moderate
AOM– 5 – 7 days: 6 years and older with mild – moderate
symptoms
91Wright, 2016
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556accessed 05-01-2013
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
92
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010Wright, 2016
OME
93Wright, 2016
OME• Treatment:
– Observation as a treatment option
– Majority – up to 90% will resolve within 3 months without intervention
– If still present at 12 weeks – may need hearing evaluation, referral to ENT
– High risk individuals may be candidates for myringotomy
94
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010Wright, 2016
Otitis Externa
95Wright, 2016
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
96Wright, 2016
17
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
97Wright, 2016
Otitis Externa
• Signs–Erythematous, edematous canal
–Pain with tragal/pinna movement
–Yellow/green discharge
–Foreign body
–Pre or postauricular lymphadenopathy
98Wright, 2016
Otitis Externa
• Plan– Diagnostic
• None• Can check culture
– Therapeutic• Remove foreign body• Irrigate canal• Erythromycin (Cortisporin) Otic Ear Solution: 4 drops qid
into affected ear x 5 days• Ciprofloxacin (Ciprodex) 3 – 4 drops tid into affected ear x
7 days
99Wright, 2016
Otitis Externa
• Plan– Therapeutic
• Warm compresses• NSAIDS/Tylenol• Prednisone• Auralgam• Wick
100Wright, 2016
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
101Wright, 2016
Pharyngitis
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18
Pharyngitis
• Epidemiology–Group A Beta Hemolytic Strep
• Most interest because of its association with severe complications
• Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis - complications
103Wright, 2016
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
104Wright, 2016
Exudative pharyngitis
Exudative pharyngitis
Differentials include:
Strep pharyngitis
Peritonsillar abscess
Mononucleosis
Viral pharyngitis
105Wright, 2016
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 mononucleosis106Wright, 2016
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
107Wright, 2016
Remember…Children with mono
have strep pharyngitis 50% of
the time
108Wright, 2016
19
Pharyngitis
• Plan– Therapeutic: Strep Pharyngitis
• PCN VK-standard• Treatment is for 10 days• Warm water gargles• Acetaminophen/NSAID’s
– Educational• Contagion• Quick improvement• Discard toothbrush
109Wright, 2016
Peritonsillar Abscess
• Generally begins as an acute febrile URI or pharyngitis
• Condition suddenly worsens– Increased fever– Anorexia– Drooling– Dyspnea– Trismus
110Wright, 2016
Peritonsillar Abscess
• Physical examination– May appear restless
– Irritable
– May lie with head hyperextended to facilitate respirations
– Muffled voice
– Stridor may be present
– Respiratory distress
111Wright, 2016
Peritonsillar Abscess
• Physical examination findings–Fiery red asymmetric swelling of
one tonsil
–Uvula is often displaced contralaterally and often forward
–Large, tender lymphadenopathy
112Wright, 2016
Peritonsillar Abscess
113Wright, 2016
Peritonsillar Abscess
114Wright, 2016
20
Important Reminder
•If respiratory distress is severe,
do not examine the pharynx
115Wright, 2016
Treatment
• Aspiration of the abscess may be performed for accurate diagnosis and treatment
• CT scan of the head and neck– Monitor airway at all times
• ENT consult is essential
• Usual management– IV antibiotics
– Inpatient management116Wright, 2016
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
117Wright, 2016
Treatment• Mainly symptomatic
– Avoid cough and cold medications in individuals < 2 years of age
• Consider the following:– Decongestants
– First generation antihistamines
– Cough suppressants
– Guaifenesin products
– Chicken soup 118Wright, 2016
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
119Wright, 2016
Pulmonary
Wright, 2016 120
21
Asthma and Asthma
Exacerbation121Wright, 2016
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
122Wright, 2016
Asthma is...
• A disease of:– Inflammation
• Primary Process
– Hyperresponsiveness
– Airway bronchoconstriction
– Excessive mucous production
123Wright, 2016AsthmaticNormal
Jeffery P. In: Asthma, Academic Press 1998.
Epithelial Damage in Asthma
124Wright, 2016
Diagnosis of Asthma
125Wright, 2016
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.”
126
National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis and Management of Asthma, Full Report 2007.
Wright, 2016
22
Diagnosis of Asthma
• History and Physical Examination
• Spirometry
• Monitoring:– Peak Flow Meters
127Wright, 2016
Symptoms and Signs of Asthma in Children
• Coughing, particularly at night• Wheezing• Chest tightness• SOB• Cold that lingers x months with a
persistent cough
128Wright, 2016
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.
129
National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis and Management of Asthma, Full Report 2007.
Wright, 2016
Figure 17-1 Classifying Asthma Severity and Initiating Treatment in Children 0 to 4 Years of Age
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Step 2Step 2
Minor limitationNone
Step 3 and consider short course of oral systemic corticosteroids
Step 3 and consider short course of oral systemic corticosteroids
Persistent
Extremely limitedSome limitationInterference withnormal activity
Several timesper dayDaily>2 days/week
but not daily≤2 days/week
SABA use for symptom control (not prevention
of EIB)
>1x/week3-4x/month1-2x/month0Nighttime awakenings
Throughout the day
Daily>2 days/week but not daily≤2 days/weekSymptoms
SevereModerateComponents of Severity
MildIntermittent
Imp
airm
ent
Risk
Step 1Step 1
In 2 to 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4 to 6 weeks, consider adjusting therapy or alternative diagnoses
In 2 to 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4 to 6 weeks, consider adjusting therapy or alternative diagnoses
Recommended Stepfor Initiating Treatment
≥2 exacerbations in 6 mos requiring oral systemic corticosteroids, or ≥4 wheezing episodes/1 year lasting >1 day & risk factors for persistent asthma
≥2 exacerbations in 6 mos requiring oral systemic corticosteroids, or ≥4 wheezing episodes/1 year lasting >1 day & risk factors for persistent asthma 0-1/year0-1/yearExacerbations requiring
oral systemic corticosteroids
Consider severity and interval since last exacerbationFrequency and severity may fluctuate over time
Exacerbations of any severity may occur in patients in any severity category
Wright, 2016 130
Stepwise Approach for Managing Asthma in Children Age 0 to 4 Years
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Step 1
Preferred:
SABA
PRN
Step 3
Preferred:
Medium-dose ICS
Step 5
Preferred:
High-dose ICS + either LABA
or Montelukast
Step 4
Preferred:
Medium-dose ICS + either
LABAor
Montelukast
IntermittentAsthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if Step 3 care or higher is required.
Consider consultation at Step 2.
Patient Education and Environmental Control at Each Step
Step Up if Needed
(first check adherence,
inhaler technique, &
environmental control)
Step Down if Possible
(& asthma is well controlled
at least 3 months)
Assess Control
Quick-Relief Medication for All Patients• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms• With viral respiratory infection: SABA q 4-6 hours up to 24 hours (longer with physician consult).• Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of
previous severe exacerbations• Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations
on initiating daily long-term-control therapy
Step 2Preferred:Low-dose
ICS Alternative:Cromolyn
or Montelukast
Step 6Preferred:
High-doseICS + either
LABA or Montelukast
and Oral Systemic
Corticosteroids
Wright, 2016 131
Classifying Asthma Severity and Initiating Treatment in Children 5 to 11 Years of Age
Step 3, med.-doseICS option, or
Step 4
Step 3, med.-doseICS option, or
Step 4
Step 3, medium-dose ICS option
Step 3, medium-dose ICS option
PersistentPersistent
Extremely limitedSome limitationMinor limitationNoneInterference withnormal activity
Several timesper dayDaily
>2 days/weekbut not daily
≤2 days/weekSABA use for symptom control(not prevention of
EIB)
Often 7x/week>1x/week but
not nightly3-4x/month2x/monthNighttime awakenings
Throughout the dayDaily
>2 days/week but not daily≤2 days/weekSymptoms
SevereSevereModerateModerateComponents of Severity
• Normal FEV1between exacerbations
• FEV1 >80%predicted
• FEV1/FVC>85%
• FEV1<60% predicted
• FEV1/FVC <75%
• FEV1=60%-80% predicted
• FEV1/FVC= 75%-80%
• FEV1 80% predicted
• FEV1/FVC >80%Lung Function
MildMildIntermittentIntermittent
Imp
airm
ent
Risk
Step 2Step 1Step 1
& consider short course of oral systemic corticosteroids
In 2 to 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordinglyIn 2 to 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly
Recommended Stepfor Initiating Treatment
Consider severity and interval since last exacerbationFrequency and severity may fluctuate over time for patients in any severity category
Consider severity and interval since last exacerbationFrequency and severity may fluctuate over time for patients in any severity category
≥2/year≥2/year0-1/year0-1/year
Relative annual risk of exacerbations may be related to FEV1Relative annual risk of exacerbations may be related to FEV1
Exacerbationsrequiring oral
systemic corticosteroids
Exacerbationsrequiring oral
systemic corticosteroids
Wright, 2016 132
23
Stepwise Approach for Managing Asthmain Children Age 5 to 11 Years
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
IntermittentAsthma
IntermittentAsthma
Persistent Asthma: Daily MedicationPersistent Asthma: Daily MedicationConsult w/ asthma specialist if Step 4 care or higher is required.
Consider consultation at Step 3.Consult w/ asthma specialist if Step 4 care or higher is required.
Consider consultation at Step 3.
Each Step: Patient education, environmental control, and management of comorbiditiesSteps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
Step Up if Needed
(first, check adherence, inhaler
technique, environmental control, and
comorbid conditionals)
Step Up if Needed
(first, check adherence, inhaler
technique, environmental control, and
comorbid conditionals)
Step Down if Possible
(and asthma is well-controlled at
least 3 months)
Step Down if Possible
(and asthma is well-controlled at
least 3 months)Quick•
• ol
Quick-Relief Medication for All Patients• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: Up to 3 treatments at 20-minute intervals
as needed. Short course of oral systemic corticosteroids may be needed• Caution: Increasing of use of SABA or use>2 days a week for symptom relief (not prevention of EIB) indicates inadequate control
and the need to step up treatment
Step 1
Preferred:SABA PRN
Step 1
Preferred:SABA PRN
Step 2
Preferred:Low-dose
ICS
Alternative:Cromolyn,
LTRA,Nedocromil,
orTheophylline
Step 2
Preferred:Low-dose
ICS
Alternative:Cromolyn,
LTRA,Nedocromil,
orTheophylline
Step 3
Preferred:
Low-dose ICS +
either LABA
LTRA orTheophylline
OR
Medium-dose ICS
Step 3
Preferred:
Low-dose ICS +
either LABA
LTRA orTheophylline
OR
Medium-dose ICS
Step 5
Preferred:High-dose ICS +
LABA
Alternative:High-dose ICS +
either LTRA
or
Theophylline
Step 5
Preferred:High-dose ICS +
LABA
Alternative:High-dose ICS +
either LTRA
or
Theophylline
Step 4
Preferred:Medium-doseICS + LABA
Alternative:Medium-dose ICS + either
LTRA or
Theophylline
Step 4
Preferred:Medium-doseICS + LABA
Alternative:Medium-dose ICS + either
LTRA or
Theophylline
Step 6
Preferred:High-dose ICS +
LABA + Oral Systemic Corticosteroid
Alternative:High-dose ICS +
either LTRA orTheophylline
+
Oral Systemic Corticosteroid
Step 6
Preferred:High-dose ICS +
LABA + Oral Systemic Corticosteroid
Alternative:High-dose ICS +
either LTRA orTheophylline
+
Oral Systemic Corticosteroid
Assess Control
Wright, 2016 133
Stepwise Approach for Managing Asthma in Patients Aged≥12 Years
www.nhlbi.nih.gov/guidelines/asthma/asthgdln
Step 1
Preferred:SABA PRN
Step 2Preferred:
Low-dose ICS (A)
Alternative:Cromolyn (A),
LTRA (A), Nedocromil (A),
orTheophylline (B)
Step 3Preferred:
Low-dose ICS + LABA (A)
OR Medium-dose
ICS (A)Alternative:Low-dose ICS + either LTRA (A), Theophylline (B),
or Zileuton (D)
Step 5
Preferred:High-dose ICS +
LABA (B)AND
Consider Omalizumabfor PatientsWho Have
Allergies (B)
Step 4Preferred:Medium-dose
ICS + LABA (B)Alternative:
Medium-dose ICS + either
LTRA (B), Theophylline (B),or Zileuton (D)
Step 6
Preferred:High-dose ICS + LABA + Oral Corticosteroid
ANDConsider
Omalizumab for Patients
WhoHave
Allergies
IntermittentAsthma
IntermittentAsthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3.
Step Up if Needed
(first, check adherence,
environmental control, and
comorbid conditions)
Step Down if Possible
(and asthma is well
controlled at least 3
months)
Assess Control
Quick-relief medication for all patients• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up
to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed
• Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment
Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
Wright, 2016 134
Major Focus in EPR-3
• Controlling asthma is a major focus of the EPR-3 guidelines
135Wright, 2016
Assessing Asthma Control (Youths 12 Years of Age and Adults)
Follow-up Visits: Determine Level of Control and Treatment NeededComponents of Control Well-controlled Not Well-
controlledVery Poorly Controlled
Impairment
Symptoms≤2 days/week >2 days/week Throughout the day
Nighttime awakenings ≤2 x/month 1-3x/week ≥4x/week
Interference with normal activity
None Some limitation Extremely limited
Short-acting beta2-agonist use for symptom control (not prevention of EIB)
≤2 days/week >2 days/week Several times per day
FEV1 or peak flow>80% predicted/personal best
60-80% predicted/personal best
<60% predicted/personal best
Validated QuestionnairesATAQACQACT
0≤0.75*≥20
1-2≥1.516-19
3-4N/A≤15
Exacerbations 0-1/year ≥2/year (see note)Consider severity and interval since last exacerbation
Risk
Progressive loss of lung function
Evaluation requires long-term follow-up care
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
*ACQ values of 0.76-1.4 are indeterminate regarding well-controlled asthma.Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second. See figure 3-8 for full name and source of ATAQ, ACQ, ACT.
136Wright, 2016
Monitoring Control in Clinical Practice: Asthma Control Test™ for Patients Aged ≥12 Years1
1. Asthma Control Test™ copyright, QualityMetric Incorporated 2002, 2004. All rights reserved.2. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/epr3/resource.pdf. Accessed February 5, 2007.
Level of Control Based on Composite
Score2
≥20 = Controlled
16-19 = Not Well
Controlled
≤15 = Very Poorly Controlled
Regardless of patient’s self
assessment of control in
Question 5
137Wright, 2016
Acute Asthma Exacerbation Management
138Wright, 2016
24
Case Study
• 6 year old who presents with a 2 day history of increasing sob and wheezing
• Began after developing a URI• + nasal discharge, wheezing, cough, fever –
99.6– Denies ST, ear pain, sinus pain, pain with
inspiration• Meds: none• Allergies: NKDA• PMH: Bronchiolitis: age 6 months –
required hospitalization139Wright, 2016
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
140Wright, 2016
Acute Asthma Exacerbation
• Measure Spirometry vs. Peak Flow• FEV1 is most important number
– >80% predicted– 50% – 79% of predicted– < 50% of predicted
141Wright, 2016
Spirometry Results
• FEV1 = 62% of predicted
• FEV1/FVC = 90%
• What does this mean for our patient?
142Wright, 2016
Acute Asthma Exacerbation
• Inhaled short acting beta 2 agonist: – Up to three treatments of 2-4 puffs by
MDI at 20 minute intervals OR a single nebulizer
• Can repeat x 1 – 2 provided patient tolerates– Albuterol or similar via nebulizer– Reassess spirometry or peak flow after
143Wright, 2016
Prednisone
• Multiple products available
• Prelone, Orapred, Prednisone– 1 mg/kg daily (may split dosage)
• Example: Prednisone 10 mg bid x 3 - 10 days
• No taper necessary
144Wright, 2016
25
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
145Wright, 2016
Patient Education
• Have plan in place for next URI
• Preventative therapy?
• Environmental modification
• Daily peak flows
146Wright, 2016
Severity of Acute Exacerbations
Wright, 2016 147http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf accessed 05-01-2014
Bronchiolitis
148Wright, 2016
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
spring149Wright, 2016
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 months150Wright, 2016
26
Burden of Illness
• Typically, bronchiolitis is a mild illness
• Risk factors for more severe illness include:–Prematurity
–Heart or lung disease
–Weakened immune system
151Wright, 2016
Complications of Bronchiolitis
• Hospitalization
• Respiratory distress
• Children with this condition are more likely to develop asthma later in life
152Wright, 2016
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
153Wright, 2016
Signs and Symptoms• Cough worsens
• Wheezes frequently occur– High pitched sounds indicating a difficulty with
air movement
• Worsening respiratory distress may occur– Retractions
– Flaring of the nostrils
– Irritability
– Tachycardia and tachypnea154Wright, 2016
Incubation Period and Duration
• Incubation period is:–Days – 1 week
–This is dependent upon which virus is responsible for the infection
• Duration of symptoms–Typically 7 days but children with severe
cases may cough for weeks
155Wright, 2016
Treatment
• Symptomatic treatment is the most common treatment– Increased fluids
– Cool mist vaporizer to thin the secretions
– Tilting the child’s mattress up may be beneficial
• Antibiotics are not helpful156Wright, 2016
27
Pharmacotherapy
• Corticosteroids
• Inhaled corticosterioids
157Wright, 2016
Bronchitis
158Wright, 2016
Bronchitis• Definition: Inflammatory condition
of the tracheobronchial tree–Acute bronchitis
• Most cases of acute bronchitis are viral (90-95%)
• 5% are bacterial
–Most frequent cause of bacterial bronchitis – atypical pathogen (i.e. mycoplasma) 159Wright, 2016
Treatment for Bronchitis
• Symptomatic
• Increase fluids
• Steam
• Guiafenesin or similar
• First generation antihistamine
• Cough syrup – usually not helpful or effective
160Wright, 2016
Bronchitis
• Treatment–Antibiotics rarely needed
• If needed, atypical pathogen coverage
–Prednisone• Short, non-tapering burst is often very
effective
• i.e. 5 days
161Wright, 2016
Pertussis
162Wright, 2016
28
163
Pertussis:Preventable but Persistent
“There is a relative lack of awareness among health-care providers that pertussis immunity from natural infection or childhood vaccination wanes 5-8 years after the last booster dose. This leaves adolescents and adults vulnerable to pertussis infection, and those infected can transmit risk of life-threatening disease to young infants.”1
Reference: 1. Healy CM, et al. Vaccine. 2009;27(41):5599-5602.
Pertussis: Highly Communicable,Frequently Overlooked
• Acute respiratory tract infection causedby Bordetella pertussis (gram-negative aerobic bacillus)1
• Highly communicable (90%-100%secondary attack rate among susceptibles)2,3
• Morbidity in all ages, especially infants1,2
• The cause of 13%-17% of cases of prolonged cough in adolescents and adults4
• Adolescents, adults with unrecognized or untreated pertussis contribute to the reservoir of B pertussis in the community and pose a risk of transmission to others1
References: 1. Centers for Disease Control and Prevention (CDC). MMWR. 2005;55(RR-14):1-16. 2. CDC. MMWR. 2006;55(RR-17):1-37. 3. Long SS: Pertussis (Bordetella pertussis and Bordetella parapartussis.) In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds, Nelson Textbook of Pediatrics. 18th edition. Philadelphia, PA: Saunders Elsevier;2007:1178-1182. 4. Cherry JD. Pediatrics. 2005;115(5):1422-1427.
Eye of Science /P
hoto Researchers, Inc.
164Wright, 2016
Reported Cases of Pertussis Are Highestin Adolescents and Adults …
• ~10,000-25,000 cases of pertussisare reported in the US every year1
• ~60% of reported cases occuramong adolescents and adults2
• Reported cases are the tip ofthe iceberg
– Estimated actual cases amongadolescents and adults:800,000-3.3 million per year3
References: 1. CDC. (Published July 9, 2009 for 2007). MMWR. 2007;56(53):1-94. 2. CDC. Data on file (Pertussis Surveillance Reports), 2003-2008. MKT 17595 (2003-2006); MKT18596 (2007); MKT 18761 (2008). 3. Cherry JD. Pediatrics. 2005;115(5):1422-1427. 4. CDC. MMWR. 2005;55(RR-14):1-16.
“Despite increasing awareness and recognition of pertussis as a diseasethat affects adolescents and adults, pertussis is overlooked in thedifferential diagnosis of cough illness in this population.”4
Courtesy of the Centers for Disease Control and Prevention (CDC).
165Wright, 2016
The Very Young are Very Vulnerable to Complications of Pertussis
AgeNo. with
pertussisa Hospitalization Pneumonia Seizures Encephalopathy Death
<6 months 7203 4543 847 103 15 56
6-11 months 1073 301 92 7 1 1
1-4 years 3137 324 168 36 3 1
References: 1. CDC. MMWR. 2002;51(4):73-76. 2. CDC. MMWR. 2005;54(RR-14):1-16.
a Individuals with pertussis may have had 1 or more of the listed complications. Data are for 1997-2000.
“Unvaccinated or incompletely vaccinated infants aged <12 months have the highest risk for severe and life-threatening complications and death.”2
Pertussis complications, hospitalizations, and deaths1
166Wright, 2016
• Multicenter study in France, Germany, Canada, US
• Study population: 95 infants ≤6 months of age with lab-confirmed pertussis
• Household members were responsible for 76%-83% of transmission to infants in 44 cases where a source could be identified
Reference: 1. Wendelboe AM, et al. Pediatr Infect Dis J. 2007;26(4):293-299.
Part-timecaretaker2% Grandparent
6%
Friend/Cousin10%
Father18%
Sibling16%
Aunt/Uncle10%
Transmitting Pertussis to InfantsIs a Family Matter1
Mother37%
“Implementation of the ACIP recommendation for adult and adolescent [Tdap] vaccination could substantially reduce the burden of infant pertussis, if high coverage rates among those in contact with young infants can be achieved.”
167Wright, 2016
October 2010 – ACIP Recommendations
• Tdap – for those over 65 years of age who have not received Tdap previously, those desiring Tdap, or those who to be in contact with infants– Ideally, 2 weeks before contact
• Interval has been removed for time between Td and Tdap
• Also – Tdap may now be given (off-label) to individuals 7 years of age (as a catch up) for children not immunized 168Wright, 2016
29
New 2013
• Tdap with each pregnancy
• Tdap may be administered any time during pregnancy, but vaccination during the third trimester would provide the highest concentration of maternal antibodies to be transferred closer to birth
• Regardless of interval and previous vaccination with Tdap
Wright, 2016 169
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm accessed 05-01-2013
Tdap Issue Remaining
• What to do with individuals who have received Tdap and are in need of another Td vs. Tdap
• Tdap revaccination (June 2013) – Meeting agenda for June 2013
– Decided NOT to universally recommend for all, other than pregnant women
Wright, 2016 170
Diagnostic Tests for Pertussis
NP culture on special media (Regan-Lowe, Bordet-Gengou)
PCR
Serologic tests
Increased WBC with an absolute lymphocytosis
DFA—variable sensitivity/specificity
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171Wright, 2016
Treatment of Cases and Chemoprophylaxis of Close
Contacts Erythromycin estolate or erythromycin ethylsuccinate
(EES) 40-50 mg/kg/day (max 2 g/day) in 2-4 divided doses for 7-14 days1*
Azithromycin 10-12 mg/kg/day (max 500mg/day) 1 dose/day for 5 days†
Clarithromycin 15-20 mg/kg/day (max 1g/day) in 2 divided doses for 7 days
Reference:1. Halperin SA. Pertussis Control in Canada [letter]. CMAJ. 2003;168(11):1389-1390.
* Use caution when using macrolides, especially erythromycin, in infants less than 2 weeks old.† Azithromycin may be given as 10-12 mg/kg/day (max 500 mg/day) on day 1 and 5 mg/kg/day (max 250 mg/day) on days 2-5.
172Wright, 2016
Treatment of Cases and Chemoprophylaxis of Close Contacts (cont’d)
• For patients allergic to macrolides:
– Trimethoprim-sulfamethoxazole 8mg TMP/40mg SMX/kg/day (max 320mg TMP/1600mg/day) in 2 divided doses for 14 days1
• All of these agents reduce transmission of B pertussisand ameliorate early symptoms2
• No antibiotic lessens the severity or shortens the duration of cough in patients who are already experiencing paroxysmal episodes1
• Penicillins/cephalosporins are not effectiveReferences:1. Edwards KM, et al. In: Plotkin SA, et al, eds. Vaccines. 1999:293-344. 2. CDC. The Pink Book, 7th ed. 2002:75-88. Available at: www.cdc.gov/nip/publications/pink/pert.pdf. Accessed March 15, 2005.173Wright, 2016
Websites with Vaccine Information
• www.pertussis.com
• www.cdc.gov/nip/vacsafe
• www.cispimmunize.org
• www.vaccine.chop.edu
• www.vaccineprotection.com
174Wright, 2016
30
Stridor
175Wright, 2016
Stridor
• Few conditions in pediatrics are as emergent and potentially life threatening as an upper airway obstruction
• Rapid identification and treatment is essential
176Wright, 2016
Differential Diagnosis for Stridor
• Differential– Laryngotracheobronchitis (croup)
– Mechanical obstruction (birth)
– Foreign body aspiration
– Peritonsillar abscess
– Epiglottitis
– Angioedema
177Wright, 2016
Croup• Causes:
– Usually caused by a virus
– RSV, Parainfluenza or Rhinovirus
• Characteristics: – Inflammation and edema of the pharynx and
upper airways
– Narrowing of the subglottic region
– + laryngospasm is frequently seen
178Wright, 2016
Croup
Subglottic narrowing179Wright, 2016
Croup• Presentation:
– Mild URI symptoms x 24 – 48 hours• Rhinorrhea, cough, low grade fever, sore
throat
– Followed by a sudden onset of:• Croupy cough, hoarseness of the voice and
stridor
– Stridor usually begins when the child awakens suddenly from a nap or during the night with a fever
180Wright, 2016
31
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
181Wright, 2016
Croup• Treatment:
– Exposure to a cool night; child often improves on the way to the ED
– Humidification or mist may be helpful
– Aerosolized racemic epinephrine can be helpful• Very short acting agent delivered via nebulizer
– Nebulizer with albuterol or beta 2 agonist may offer some benefit
– Inhaled corticosteroids/prednisone is frequently beneficial
182Wright, 2016
Treatment
• Symptomatic treatment is the most common treatment– Increased fluids
–Cool mist vaporizer to thin the secretions
–Tilting the child’s mattress up may be beneficial
• Antibiotics are not helpful183Wright, 2016
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
184Wright, 2016
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. influenzae185Wright, 2016
Pneumonia
• Children > 5 years – Mycoplasma, S. pneumoniae, Chlamydia
pneumoniae
• Physical Examination– Vital signs
– Respiratory distress
– Auscultate lungs (egophony, bronchophony)
– Palpate for tactile fremitus
186Wright, 2016
32
Pneumonia
• Diagnostic–Chest Xray is recommended for all
suspected cases of pneumonia
187Wright, 2016
Treatment of CAP• < 5 years of age
– Presumed bacterial pneumonia• Amoxicillin (90 mg/kg/day) in two divided doses OR
• Amoxicillin/clavulanate (90mg/kg/day) in two divided doses
– Presumed atypical pneumonia• Azithromycin (10 mg/kg on day followed by 5 mg/kg/day
on days 2-5)
• Clarithromycin (15mg/kg/day) in two divided doses x 7-14 days OR
• Erythromycin (40 mg/kg/day) in four divided doses
Wright, 2016 188http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed 05-01-2013
Treatment of CAP• > 5 years of age
– Presumed bacterial pneumonia• Amoxicillin (90 mg/kg/day) in two divided doses OR
• Amoxicillin/clavulanate (90mg/kg/day) in two divided doses
• Consider adding macrolide is unclear etiology
– Presumed atypical pneumonia• Azithromycin (10 mg/kg on day followed by 5 mg/kg/day on days 2-5)
• Clarithromycin (15mg/kg/day) in two divided doses x 7-14 days OR
• Doxycycline for children > 7 – 8 years of age
Wright, 2016 189http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed 05-01-2013
Cardiac
Wright, 2016 190
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
191Wright, 2016
Cause of Chest Pain in Children• Precordial Catch – (Texidor’s twinge)
– Most common cause of chest pain
– An innocent cause of chest pain
• Very typical history:– Sporadic (entirely random)
– LSB (always same place)
– Quality – sharp
– Radiation: fingerpoint
– Mild – severe
– Lasts < 2 minutes
– Respirations make it worse!!192Wright, 2016
33
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
193Wright, 2016
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?
194Wright, 2016
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 examination195Wright, 2016
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 history196Wright, 2016
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
197Wright, 2016
GI/GU
198Wright, 2016
34
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
199Wright, 2016
Causes of Chronic or Recurrent Pain
• Constipation
• Musculoskeletal pain
• Lactose intolerance vs. celiac disease
• Colitis vs. Crohn’s
• IBS
200Wright, 2016
201
Diarrhea
Wright, 2016 202
Statistics
• Common complaint worldwide– Millions of individuals develop diarrhea every year
• Young and old individuals at increased risk from this condition– Increased risk of dehydration
– Increased risk of death
Wright, 2016
203
Pathophysiology
• 4 basic mechanisms causing diarrhea– Retention of water within the intestine
• Malabsorptive syndrome; lactose intolerance
• Maalox can produce diarrhea through this mechanism
– Excessive secretion of water and electrolytes into the intestinal lumen
• Cholera; E. Coli, Crohn’s disease, laxatives
– Release of protein and fluid into the intestinal mucosa• Ulcerative colitis, Crohn’s disease, Infections
– Altered intestinal motility resulting in rapid transport through the colon
• IBS, Scleroderma
Wright, 2016 204
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
Wright, 2016
35
205
History
• Any other family/friends ill?
• Any recent trips/camping?
• Food intake?– Any nonpasturized ciders?
– Any beef?
– Uncooked meats?
– Mayonnaise?
• Medications?
Wright, 2016 206
Symptoms
• Sudden onset• Frequent bowel movements• Loose, watery stools• Bloody stools• Abdominal cramping• Thirst• Decreased urination• Dizziness• Fatigue
Wright, 2016
207
Physical Examination
• Generally unremarkable• Tachycardia• Poor turgor• Orthostatic signs• Hyperactive bowel sounds (borborygmi)• Tender abdomen• Heme positive stool, possibly (E. Coli)• Fecal impaction
Wright, 2016 208
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
Wright, 2016
209
Gastroenteritis
• Signs– Temperature
– Diffuse tenderness
– No obturator, psoas or markle’s sign
– Dehydration• No urination or tears in 8 hours constitutes
dehydration in children
Wright, 2016 210
Gastroenteritis
• Diagnosis– History and physical examination– Fecal leukocytes
• Salmonella, Shigella, Amoeba and Campylobacter all invade the intestinal mucosa and therefore cause leukocytes
• Inflammatory bowel disease (Colitis, Crohn’s)• E. coli, viral etiologies do not generally produce
these cells
Wright, 2016
36
211
Gastroenteritis
• Stools for O&P– Entamoeba histolytica– Giardia lamblia
• Stools for C&S– Salmonella or Shigella– Need to request specific tests for E. Coli, Yersinia,
and Campylobacter
• C. difficile– Previous antibiotic therapy
Wright, 2016 212
Gastroenteritis
• Treatment– Fluids– BRATT diet
• Avoid lactose
– Antibiotics• Depending upon the pathology-antibiotic regimen varies
– IV rehydration– Hospitalization– Anti-motility agents (controversial)
Wright, 2016
Constipation
• Normal frequency of BM’s: 3 / day – 3 per week
• Focus is shifting more toward comfort with BM’s rather than number
• Most common GI complaint in the US
• Always ask regarding following:– Weight loss, blood in stool, abdominal pain,
anorexia, vomiting, anemia
213Wright, 2016
Constipation
• Options for treatment–Fiber intake
–Polyethylene glycol (Miralax)
–Lactulose
–Milk of Magnesia
–Behavioral modification
214Wright, 2016
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?215Wright, 2016
Appendicitis
• Inflammation/Infection of the Appendix– Can lead to ischemia and perforation of the
appendix
• Etiology– Most common age: 10-19 years
– Incidence: 1.1/1000 Persons each year
– Males>females
– Whites>Nonwhites
– Summer-most common time of year
– Midwest-highest incidence 216Wright, 2016
37
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
217Wright, 2016
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
218Wright, 2016
Clinical Pearl
The presence of pain before vomiting is highly suggestive
of appendicitis.
Diarrhea before pain is more likely to be gastroenteritis.
219Wright, 2016
Physical Examination
• Abdominal Examination– Tenderness at McBurney’s point
• 1/3 the distance between the anterior iliac spine and the umbilicus
– Guarding• Contraction of the abdominal walls
• Frequently present
220Wright, 2016
Physical Examination
• Rigidity– Important predictor of appendicitis
– Involuntary spasm of the abdominal musculature
– Caused by peritoneal inflammation
• Markle’s sign– Heel-drop jarring test
221Wright, 2016
Physical Examination• Rebound tenderness
– Press on area above the pain
– Suddenly withdraw fingers
• Rovsing’s Sign– Pain felt in RLQ when examiner presses firmly in
the LLQ and suddenly withdraws
• Psoas Sign– Patient is placed in a supine position
– Ask patient to lift thigh against your hand that you have placed above the knee 222Wright, 2016
38
Physical Examination
• Obturator Sign– May be or may not be positive
– Patient is positioned in supine position with the right hip and knee flexed
– Internally rotate the right leg
• Internal Examination– Consideration to an ovarian cyst
• Rectal Examination– May be considered
223Wright, 2016
Laboratory/Radiologic Testing
• CBC with differential– Normal wbc count doesn’t rule-out the diagnosis
– White blood cell count may actually decrease
– Look for wbc left shift
• Elevated wbc
• Elevated neutrophils
• Elevated bands
224Wright, 2016
Laboratory/Radiologic Testing
• Urinalysis
• CT Scan vs. Ultrasound – Emerging evidence that US may be as effective
as CT scan for individuals with appendicitis
– Many hospitals are moving to US first approach to reduce radiation exposure
225Wright, 2016
http://www.sciencedaily.com/releases/2013/12/131202171811.htm accessed 05-01-2014
UTI
• Gram negative bacilli are the most common pathogens (Escherichia coli)
• Staphylococcus saprophyticus – more likely in young, sexually active women
• Preschoolers and young children will likely present with symptoms similar to an adult– Dysuria, urgency, frequency
• Must r/o or consider pyelonephritis
226Wright, 2016
UTI• Urinary dipstick findings
– Leukocytes
– Nitrites
– RBC’s
• Treatment– Trimethoprim/sulfamethoxazole (8 – 10 mg/day of
trimethoprim
– Cefixime (Suprax) in children > 6 years
– Cefpodixime (Vantin)
– Treatment: 7 days – 10 days227Wright, 2016
Screening
• Routine screening for C. trachomatis of all sexually active females aged ≤ 25 years is recommended annually
• Routine screening for N. gonorrhoeae in all sexually active women < 25 years of age at risk for infection is recommended annually
Wright, 2016 228
http://www.cdc.gov/std/treatment/2010/specialpops.htm accessed 06-10-2015
39
Enuresis• Definition: involuntary urination at night after
5 years of age in girls and 6 years of age in boys– Small percentage have diurnal enuresis
• Differentials (particularly if dry in past)– Urinary tract infection
– Emotional issues (divorce, new baby)
– Type 1 diabetes
– Neurologic abnormalities
– Constipation229Wright, 2016
Enuresis
• Treatment Options– Desmopressin (DDAVP )(Nasal spray no
longer approved for this indication)
– Tricyclic antidepressants (caution advised)
– Bed wetting alarm
– Bladder training
– Constipation treatments
230Wright, 2016
Preparticipation Examination
Wright, 2016 231
School Physical Examination
• Help to maintain the health and safety of the young athlete by...– Detecting conditions that may predispose to
injury (obesity, recurrent ankle sprains)– Detect conditions that may be life threatening
(hypertrophic cardiomyopathy)
• Goal to not to exclude an individual from sport’s participation– But…to find any problems that might worsen
with particular activities
232Wright, 2016
Millions of Young Athletes
• Millions of young athletes are involved in a variety of activities
233Wright, 2016
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
234Wright, 2016
40
Kids Just Want to Have Some Fun!!
235Wright, 2016 236
Frequency
• AAP recommends examinations every 2 years
• Many schools have different recommendations
http://www.emedicine.com/sports/TOPIC156.HTM#section~TimingFrequencyandTypesofEvaluations accessed 02-10-2010
Wright, 2016
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
237
http://pedsinreview.aappublications.org/cgi/content/extract/22/6/199 accessed 02-10-2010
Wright, 2016 238Wright, 2016
Sprains/strains• Most frequently encountered in children:
– Ankles – number 1
– Fingers
– Knees
• Differentiation between various grades – First degree: minimal pain, joint stable
– Second degree: severe pain, minimal joint instability
– Third degree: severe pain and complete instability
239
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY, NY: The McGraw-Hill Companies.Wright, 2016
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
240
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY, NY: The McGraw-Hill Companies.
Wright, 2016
41
Fractures
• Most common in children:– Fingers, toes, distal radius, clavicle, ankle
• Assessment– Capillary refill
– Surrounding skin
– Sensation
• Treatment– Stabilization, elevation, ice
– Casting241Wright, 2016
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
242Wright, 2016
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 needed243Wright, 2016
Osgood Schlatter Disease• Most common in later childhood and early
adolescence
• Painful swelling and tenderness of the tibial tuberosity
• Treatment:– Decrease quad loading and bending
– RICE treatment protocol
– Quad and hamstring stretching
– NSAID as needed
244Wright, 2016
Neurologic Conditions
245Wright, 2016
Headache
• Headaches are common in childhood and adolescence
• Primary headaches account for 90+% of all headaches:– Migraine
– Tension
– Cluster
246Wright, 2016
42
Headache
• Indications for Headache Work-up–Systemic symptoms
–Neurologic signs and symptoms
–Onset
–Older (< 5 or > 50)
–Previous headache
Dodick DW. Adv Stud Med. 2003;3:87-92. 247Wright, 2016
Treatment for Headaches
• Tension:– NSAID or acetaminophen
– Rest and heat
• Migraine– NSAID or acetaminophen
– Trigger Avoidance
– Triptan (rizatriptan and almotriptan approved in children)
– Preventative therapies, as indicated248Wright, 2016
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
249http://www.aafp.org/afp/20050601/tips/13.html accessed 08-22-2008Wright, 2016
Syncope
250http://www.aafp.org/afp/20050601/tips/13.html accessed 08-22-2008Wright, 2016
Concussion Guidelines
Wright, 2016 251
http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013
What Is A Concussion?• A concussion is a disturbance in brain function caused
by a direct or indirect force to the head
• Results in a variety of non-specific signs and / or symptoms and most often does not involve loss of consciousness
• Should be suspected in the presence of any one or more of the following:
– Symptoms (e.g., headache), or
– Physical signs (e.g., unsteadiness), or
– Impaired brain function (e.g. confusion) or
– Abnormal behavior (e.g., change in personality)Wright, 2016 252
http://bjsm.bmj.com/content/47/5/259.full.pdf accessed 05-18-2013
43
Concussions
• Confusion and amnesia will occur immediately after event
• Often accompanied by headache, dizziness, nausea and/or vomiting
• Symptoms following a concussion may last up to 3 months or longer
• Concussions are more likely to occur within 10 days of a previous concussion
253Wright, 2016
http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013
254
Concussion
Wright, 2016
http://knowconcussion.org/wp-content/uploads/2011/06/graded_symptom_checklist.pdfaccessed 05-19-2013
Administer prior to season; administer immediately after injury.Return to play when symptoms are consistent with baseline score
Return to Play
Wright, 2016 255
http://bjsm.bmj.com/content/47/5/259.full.pdf accessed 05-18-2013
This tool is not used alone but provides guidance for return to playShould NOT be returned to play on day of concussion
Dermatologic Conditions
256Wright, 2016
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
257Wright, 2016
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
258Wright, 2016
44
Verruca Vulgaris
259Wright, 2016
Verruca Vulgaris• Treatment
– OTC product: salicylic acid topical (Compound W) or similar– OTC cryosurgery kit– Liquid nitrogen– Duct tape– Cryosurgery in office– Cimetidine
• Immunomodulatory effects at high dosages; effects varied– Imiquimod– Tretinoin type products– Electrocautery– Blunt dissection (plantar lesions)
260Wright, 2016
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)
261Wright, 2016
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
262Wright, 2016
Urticaria
263Wright, 2016
Urticaria
• Plan–Therapeutic
• Stop medications if possible
• Stop suspected foods or drinks
• Cool compresses
• Antihistamines/H2RA
• Prednisone
264Wright, 2016
45
Urticaria
• Plan–Educational
• Avoid causes
• Educate regarding possible etiology
• Discuss side effects of antihistamines (sedation)
265Wright, 2016
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
months266Wright, 2016
Impetigo
• Symptoms:– Rash that will not go away
– Begins as a small area and then increases in size
– Yellow, crusted draining lesions
• Physical Examination Findings– Small vesicle that erupts and becomes yellow-
brown
– Initially, looks like an inner tube
– Crust appears and if removed, is bright red and inflamed 267Wright, 2016
Impetigo
268Wright, 2016
Impetigo• Physical Examination Findings
–2-8 cm in size
• Diagnosis–Diagnostic:
• Culture – Today, must absolutely consider MRSA
–Therapeutic:• Mupirocin topical (Bactroban) or retapamulin
topical (Altabax)• 1st generation cephalopsporin vs. TMP/SMX
269Wright, 2016
Impetigo
• Educational–Good handwashing and hygiene
–No school/daycare for 24 - 48 hours
–Wash sheets and pillowcases
–Monitor for serious sequelae
270Wright, 2016
46
CA - MRSA
Wright, 2016 271
CA-MRSA
Wright, 2016 272
CA-MRSA
• Current estimates:– 25 – 30% of people carry colonies of
staphylococci in their noses
– < 2% are colonized with MRSA
Wright, 2016 273
IDSA Published Information
Wright, 2016 274
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
Wright, 2016 275
Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin –Resistant
Staphylococcus aureus Infections in Adults and Children: Executive Summary
Wright, 2016
Liu, Catherine et. al. MRSA Treatment Guidelines CID 2011:52 (1 February) 285-292276
47
2014: Updated Practice Guidelines
Wright, 2016 277http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.fullaccessed 02-01-2015
Treatment for Purulent Mild CA-MRSA
• No significant risk factors for adverse outcomes
• I&D is the treatment of choice
• Antibiotics are not necessary
Wright, 2016 278
Antibiotics Indicated
• Abscesses associated with the following:– Severe or extensive disease
– Rapid progression in presence of cellulitis
– Signs and symptoms of systemic illness
– Associated comorbidities or immunosuppression
– Extremes of age
– Abscess in area unable to be drained
– Lack of response to I&D alone
Wright, 2016 279
Statistics/Treatment in My Community
• 37% of staph infection at DHMC – MRSA
• Nationally, approximately 50% are MRSA
• CA-MRSA antibiotic susceptibility– 50% will be resistant to clindamycin
• TMP/SMX has best coverage/sensitivity: 96-98%– Important for clinicians to obtain own antibiogram
for communities in which you serviceWright, 2016 280
IDSA Recommendations
Wright, 2016 281
Treatment and Eradication Strategies: Recurrent infections
• GOOD handwashing
• Treatment with Bactrim,clinda, TCN, Linezolid
• Bathe with disinfectants– Hibiclens, phisodex, clorox bleach
• Utilize topical disinfectants– Purell
– Mupirocin – seeing resistance
Wright, 2016 282
48
IDSA: Decolonization RegimensNo role for oral antimicrobials
Wright, 2016 283
Preoperative Screening Study
• 1,200 primary total hip arthroplasty or total knee arthroplasty patients underwent preoperative Staphylococcus nasal screening between January 2009 and July 2009
• 1,100 patients who underwent elective TJA between July 2008 and December 2008 served as the control group
• Nasal swab at least 14 days before their procedure; those who tested + were treated with mupirocin bid x 5 days intranasally and chlorhexidine baths daily x 5 days
• Reduced surgical site infections by 82%
Wright, 2016http://www.aaos.org/news/aaosnow/apr11/clinical9.asp accessed 12-27-2013284
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 ageWright, 2016 285
Bites and Stings• Insect Sting
– Reaction to wasp or yellow-jacket sting can begin within minutes – up to 60 minutes
– Anaphylaxis can occur within minutes in the individual with allergy
• Treatment:– Remove stinger, if present
– Oral antihistamine
– Ice pack and elevate
– Anaphylaxis history: Epi Pen with instructions286Wright, 2016
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
287Wright, 2016
This is NOT a Lyme Bearing Tick
288Wright, 2016
49
Lyme Bearing Tick
289Wright, 2016
Erythema Chronicum Migrans
• Symptoms• 3-21 days after bite
• Rash (present in 72-80% of cases)-slightly itchy
• Lasts 3-4 weeks
• Mild flu like symptoms (50% of time)
• Migratory joint pain
• Neurological and cardiac symptoms
• Arthritis, chronic neurological symptoms
Wright, 2016 290
Erythema Chronicum Migrans• Signs
– Rash:
• 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:
• Asymmetric joint erythema, warmth, edema
• Knee is most common locationWright, 2016 291
Erythema Migrans
Wright, 2016292
Erythema Migrans
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Summer 2009
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50
Erythema Chronicum Migrans
• Signs– Systemic symptoms
• Facial palsy
• Meningitis
• Carditis
Wright, 2016 295
Erythema Chronicum Migrans
• Plan– Diagnostic:
• Sed rate: usually normal
• 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
Wright, 2016296
Per ILADS• “Diagnosis of Lyme disease by two-tier confirmation fails to
detect up to 90% of cases and does not distinguish between acute, chronic, or resolved infection”
• “The Centers for Disease Control and Prevention (CDC) considers a western blot positive if at least 5 of 10 immunoglobulin G (IgG) bands or 2 of 3 immunoglobulin M (IgM) bands are positive. However, other definitions for western blot confirmation have been proposed to improve the test sensitivity. In fact, several studies showed that sensitivity and specificity for both the IgM and IgG western blot range from 92 to 96% when only two specific bands are positive”– Lyme specific bands: 31, 34, and 39
Wright, 2016
http://www.ilads.org/lyme_disease/treatment_guidelines_clearing_ilads.htmlAccessed 12-20-2013 297
Erythema Chronicum Migrans
• Plan– Therapeutic: Per CDC
• Amoxicillin 500mg tid x 21 – 28 days
• Doxycycline 100 mg 1 po bid x 21 – 28 days
• If in endemic area and tick is partially engorged, may treat with doxycycline 200 mg x 1 dose with food
Wright, 2016 298
ILADS
• Believe in Chronic Lyme Disease
• Treatment may be continued as long as needed to treat symptoms
• Alternative recommendations are made:– Doxycyline 100-200 mg bid or TCN 500 mg 1
bid
– Clarithromycin 500 mg 1 po bid along with hydroxychloroquine 200 mg 1 two times daily
– Azithromycin 500 mg once dailyWright, 2016 299
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 300Wright, 2016
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Pityriasis Rosea
• Symptoms– Rash initially begins as a herald patch
– Often mistaken for ringworm
– 29% have a recent history of a viral infection
– Asymptomatic, salmon colored, slightly itchy rash
• Signs– Prodrome of malaise, sore throat, and fever may precede
– Herald patch: 2-10cm oval-round lesion appears first
– Most common location is the trunk or proximal extremities
301Wright, 2016
Pityriasis Rosea
302Wright, 2016
Pityriasis Rosea• Signs
– Eruptive phase
• Small lesions appear over a period of 1-2 weeks
–Fine, wrinkled scale
–Symmetric
–Along skin lines
–Looks like a drooping pine tree
–Few lesions-hundreds
–Lesions are longest in horizontal dimension303Wright, 2016
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
304Wright, 2016
Pityriasis Rosea
• Diagnosis– History and physical examination
• Plan– Diagnostic
• Can do a punch biopsy if etiology uncertain–Pathology is often nondiagnostic
–Report: spongiosis and perivascular round cell infiltrate
• Consider an RPR to rule-out syphilis305Wright, 2016
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
• Reassurance306Wright, 2016
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Molluscum Contagiosum
• Infection caused by the pox-virus
• Most commonly seen on the face, trunk and axillae
• Self-limiting
• Spread by auto-inoculation
• Incubation period: 2-7 weeks after exposure
• Contagious until gone
307Wright, 2016
Molluscum Contagiosum• Asymptomatic lumps
• May have 1 - hundreds
• Physical Examination– 2-5mm papule with an umbilicated center
– Flesh toned - white in color
– Most often around the eye in children
– Scaling and erythema around the periphery of the lesion is not unusual
308Wright, 2016
Molluscum Contagiosum
309Wright, 2016
Molluscum Contagiosum• Plan
– Diagnostic: None or KOH prep looking for inclusion bodies
– Therapeutic: Conservative treatment is the best for children
• Curettage
• Cryosurgery
• Tretinoin
• Salicylic Acid (Occlusal)
• Laser
• TCA 310Wright, 2016
Molluscum Contagiosum
• Plan– Educational
• May resolve on own in 6 - 9 months
• Contagious until lesions are gone
• Benign
• Recurrence very common
311Wright, 2016
Scabies
• Etiology–Contagious disease caused by a mite
–Common among school children
–Adult mite is 1/3 mm long
–Front two pairs of legs bear claw-shaped suckers
312Wright, 2016
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Scabies• Etiology
– Infestation begins when a female mite arrives on the skin surface
– Within an hour, it burrows into the stratum corneum
• Lives for 30 days
• Eggs are laid at the rate of 2-3 each day
• Fecal pellets are deposited in the burrow behind the advancing female mite
• (Scybala)-feces are dark oval masses that are irritating and often responsible for itching
313Wright, 2016
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
314Wright, 2016
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
315Wright, 2016
Scabies
316Wright, 2016
Scabies
•
317Wright, 2016
Scabies
• Diagnosis–Scraping to look for mite, eggs or
feces
• Plan–Diagnostic: Scraping–Therapeutic
• Permethrin 5% cream
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54
Scabies• Plan
– Therapeutic
• Sulfur (6% in petroleum or cold cream qd x 3 days)
• Antihistamine
– Educational
• Cut nails short
• Scratching spreads the mites
• Itching can last for weeks
• Treat all family members319Wright, 2016
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 weeks320Wright, 2016
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
321Wright, 2016
Treatment
• Treat hair with pediculicide and comb nits daily
• Machine wash all in hot water cycle (130 degrees F or dry clean items
• Put items which can’t be cleaned into a plastic bag and seal it for two weeks
• Soak combs and brushes for one hour in rubbing alcohol or Lysol
• Vacuum the floor and furniture322Wright, 2016
Prescription Lice ProductsBenzyl
alcohol, 5% (Ulesfia)1
Malathion, 0.5%(Ovide)2
Spinosad, 0.9%
(Natroba)3
Ivermectin, 0.5%
(Sklice Lotion)4
Lindane,1%5
Age indication
≥6 mo Safety not shown <6 y
≥4 y ≥6 mo Use w/caution in those <110 lb
Dosage 4-48 oz(varies with hair length)
2-oz bottles; apply enough to
wet hair and scalp
Up to 120 mL (1 bottle)
depending on hair length
Up to 120 mL ( 4-oz tube)
1-2 oz depending on
hair length and density
Time of application
10 min; repeat
treatmentafter 7 d
8–12 hrs; repeattreatment in7-9 d if lice
present
10 minutes; repeat
treatment in7 d if lice present
10 minutes; tube is intended for
single use only; consult HCP
prior to re-treatment
4 min;do not re-treat
References: 1. Ulesfia Prescribing Information. Atlanta, GA: Shionogi Pharma, 2010. 2. Ovide Prescribing Information. Hawthorne, NY: Taro Pharmaceuticals, 2011. 3. Natroba Prescribing Information. Carmel, IN, ParaPRO, 2011. 4. Sklice Lotion Prescribing Information. Swiftwater, PA: Sanofi Pasteur Inc., 2012. 5. Lindane Prescribing Information. Morton Grove, IL: Morton Grove Pharmaceuticals, 2005.
17Wright, 2016 323
Keeping Kids in School
• The AAP and National Association of School Nurses state: No healthy child should be allowed to miss school timebecause of head lice1,2
• “No-nit” policies for return to school should be abandoned1,2
• School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not cost-effective2
• School nurses in concert with other health-care providers should become involved in helping school districts develop evidence-based policies1
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting, position statement, National Association of School Nurses, 2011. http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/40/Pediculosis-Management-in-the-School-Setting-Revised-2011. Accessed July 16, 2012. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
22Wright, 2016 324
55
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
325Wright, 2016
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
326Wright, 2016
327
Atopic Dermatitis
• Etiology
– Most common inflammatory skin disease if childhood
– Affects 10-12% of all children
– Caused by an inflammation in response to an allergen, chemical or an unidentified etiology
– Often occurs in an individual with a family history of allergies
– 50% of eczematous children will develop allergic rhinitis, asthma
Wright, 2016 328
Etiology
• High levels of serum IgE are common– Higher the levels of IgE-more severe the case
• Proliferation of T-helper 2 cells; Th-2 cells produce cytokines
• Cytokines cause an inflammatory response in the skin
Wright, 2016
329
Atopic Dermatitis
• Signs–Pruritic, erythematous dry patches
–Cracking and fissuring
–Lichenification (Thickening of the skin)
–Excoriations (Caused by scratching)
–Diffuse borders (different than psoriasis)
Wright, 2016 330
Diagnosis?
Wright, 2016
56
331
Common Locations
• Infants: scalp, face, and extensors
• Children: neck, flexor folds, feet
Wright, 2016 332
Atopic Dermatitis
• Plan–Diagnostic
• None
–Therapeutic• Lubrication: Most important part
• Perform multiple times daily; particularly after a bath
Wright, 2016
333
Atopic Dermatitis• Therapeutic
• Limit number of baths or showers– Avoid harsh soaps
• Antihistamines: OTC or prescription
• Low potency topical corticosteroids
• Immunomodulator (Elidel or Protopic)
• Avoids soaps, bath gels, bubble baths, shower gels
• Intralesional injections of corticosteroids
• Oral corticosteroidsWright, 2016 334
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
Wright, 2016
335
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
Wright, 2016 336
Diagnosis?
Wright, 2016
57
337
Acne Vulgaris• Diagnosis
– History and physical examination
• Plan– Diagnostic: None
– Therapeutic• Benzoyl Peroxide
• Topical Antibiotics
• Oral Antibiotics
• Tretinoin
• OCPs
• Isotretinoin (Accutane)Wright, 2016
Chickenpox (Varicella)
• Highly contagious viral infection
• Varicella-zoster virus
• Affects most children before puberty
• Peak incidence is March-May
• Spread via airborne droplets or vesicular fluid
• Contagious for 1 - 2 days before rash until lesions crust
• Incubation period-up to 21 days
338Wright, 2016
Chickenpox (Varicella)
• No prodrome or very mild
• Rash usually begins on the trunk and scalp and then spreads peripherally
• Moderate to intense itching
• Fever: 101-105
• Lesions erupt for 4 days
339Wright, 2016
Chickenpox (Varicella)
• Physical Examination Findings– Lesions 2-4 mm papule (rose petal)
– Thin walled clear vesicle (dew drop)
– Vesicle becomes umbilicated within 8-12 hours
– Followed by crusts
– Lesions are in all stages – hallmark of this disease
340Wright, 2016
Chicken Pox
341Wright, 2016
Chickenpox (Varicella)
• Plan– Diagnosis: None
– Therapeutic: Symptomatic Treatment
• NO ASPIRIN
• Clip Nails
• Caladryl or Benadryl
• Antiviral
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58
Chickenpox (Varicella)
• Plan– Education:
• Call immediately for worsening of symptoms
• Contagious until all lesions crust
• Caution of pregnant women and others without immunity
• Monitor for secondary complications
• Prevention: Varicella vaccine
343Wright, 2016
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
344Wright, 2016
Tinea Corporis
345Wright, 2016
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
346Wright, 2016
Herpes Simplex Virus
• HSV 1 and 2
• Spread in 3 manners– Respiratory droplets
– Contact with an active lesion
– Contact with fluid such as saliva
• 90% of primary infections are asymptomatic
• Symptoms usually occur 3 - 7 days after contact
347Wright, 2016
Herpes Simplex Virus
• Symptoms
–Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling
348Wright, 2016
59
Herpes Simplex Virus
• Physical Examination Findings– Grouped vesicles on an erythematous base
– Gingivostomatitis: Erythematous, edematous gingiva that bleed easily with small, yellow ulcerations
• Yellowish-white debris develops on mucosa
• Halitosis
• Lymphadenopathy
349Wright, 2016
Herpes Simplex Virus
350Wright, 2016
Herpetic Gingivostomatitis
351Wright, 2016
Herpes Simplex Virus• Plan
– Diagnostic
• Viral Culture
• HSV IgG & IgM serum antibodies
• Most accurate: HerpeSelect
– Therapeutic
• Antiviral
• Pain reliever
• Cool rinses
• Oragel 352Wright, 2016
Herpes Simplex Virus• Plan
– Educational:
• Prevent contact with infected individuals
• Discussion regarding asymptomatic shedding
• Prevent recurrences
• Call for worsening of symptoms (I.e. inability to drink, no urination x 8 hours)
353Wright, 2016
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
354http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010Wright, 2016
60
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
355http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010Wright, 2016
Roseola
• Treatment–Ibuprofen
–Acetaminophen
–Tepid baths• Cautiously with
fever
356http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010Wright, 2016
Fifth’s Disease (Erythema Infectiosum)
• Human Parvovirus B19– Occurs in epidemics
– Occurs year round: Peak incidence is late winter and early spring
• Most common in individuals between 5-15years of age– Period of communicability believed to be from exposure
to outbreak of rash
– Incubation period: 5-10 days
– Can cause harm to pregnant women and individuals who are immunocompromised 357Wright, 2016
Fifth’s Disease (Erythema Infectiosum)
• Low grade temp, malaise, sore throat– May occur but are less common
• 3 distinct phases– Facial redness for up to 4 days
– Fishnet like rash within 2 days after facial redness
– Fever, itching, and petecchiae
• Petecchiae stop abruptly at the wrists and ankles
– Hands and feet only358Wright, 2016
Fifth’s Disease (Erythema Infectiosum)
• Physical Examination Findings– Low grade temperature
–Erythematous cheeks• Nontender and well-defined borders
–Netlike rash• Erythematous lesions with peripheral white rims
• Rash-remits and recurs over 2 week period
–Petecchiae on hands and feet 359Wright, 2016
• Fifth’s Disease
360Wright, 2016
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Fifth’s Disease
361Wright, 2016
Fifth’s Disease (Erythema Infectiosum)
• Diagnosis/Plan– Parvovirus IgM and IgG
– IgM=Miserable and is present in the blood from the onset up to 6 months
– IgG=Gone and is present beginning at day 8 of infection and lasts for a lifetime
– CBC-May show a decreased wbc count
362Wright, 2016
Fifth’s Disease (Erythema Infectiosum)
• Diagnosis/Plan– Was contagious before rash appeared therefore, no
isolation needed• Spread via respiratory droplets
– Symptomatic treatment
– Patient education-I.e. contagion, handwashing
– Can cause aplastic crisis in individuals with hemolytic anemias
– Concern regarding: miscarriage, fetal hydrops
– Adults: arthralgias363Wright, 2016
Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Caused by the coxsackie virus A16 and now…A6
• Most common in children
• 2-6 day incubation period
• Occurs most often in late summer-early fall
• Symptoms– Low grade fever, sore throat, and generalized malaise
– Last for 1-2 days and precede the skin lesions
– 20% of children will experience lymphadenopathy
364Wright, 2016
cdc.gov• From November 7, 2011, to February 29, 2012, CDC received reports of 63
persons with signs and symptoms of HFMD or with fever and atypical rash in Alabama (38 cases), California (seven), Connecticut (one), and Nevada (17).
• Coxsackievirus A6 (CVA6) was detected in 25 (74%) of those 34 patients
• Rash and fever were more severe, and hospitalization was more common than with typical HFMD.
• Signs of HFMD included fever (48 patients [76%]); rash on the hands or feet, or in the mouth (42 [67%]); and rash on the arms or legs (29 [46%]), face (26 [41%]), buttocks (22 [35%]), and trunk (12 [19%])
• Of 46 patients with rash variables reported, the rash typically was maculopapular; vesicles were reported in 32 (70%) patients
• Of the 63 patients, 51 (81%) sought care from a clinician, and 12 (19%) were hospitalized. Reasons for hospitalization varied and included dehydration and/or severe pain
• No deaths were reported Wright, 201636
Hand, Foot, and Mouth Disease –A6
Wright, 2016 366http://wwwnc.cdc.gov/eid/article/18/2/11-1147-f1.htm accessed 05-01-2013
62
Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Physical Examination Findings– Oral lesions are usually the first to appear
• 90% will have
– Look like canker sores; yellow ulcers with red halos
– Small and not too painful
– Within 24 hours, lesions appear on the hands and feet
• 3-7 mm, red, flat, macular lesions that rapidly become pale, white and oval with a surrounding red halo
• Resolve within 7 days 367Wright, 2016
Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Physical Examination Findings–Hand/feet lesions
• As they evolve – may evolve to form small thick gray vesicles on a red base
• May feel like slivers or be itchy
368Wright, 2016
Hand Foot and Mouth Disease
369Wright, 2016
Hand Foot and Mouth Disease
370Wright, 2016
Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Plan–Diagnostic: None
–Therapeutic• Tylenol
• Warm baths
• Oragel or diphenhydramine/Maalox
• Magic mouthwash371Wright, 2016
Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Plan– Educational
• Very contagious (2d before -2 days after eruption begins)
• Entire illness usually lasts from 2 days – 1 week
• Reassurance
• No scarring
372Wright, 2016
63
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
373
http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2016
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
374http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2016
Kawasaki Disease
• Coronary artery aneurysms develop in 15% to 25% of untreated children
• May lead to ischemic heart disease orsudden death
• Treatment– IV immunoglobulin
– Aspirin
– Echocardiography and cardiac consult
375http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2016
Necrotizing Fasciitis
• Severe, deep, necrotizing infection
• Involves subcutaneous tissue down into the muscles
• Spreads rapidly
• Caused by Group A Beta Hemolytic Strep, Staph, Pseudomonas, E Coli
• Mortality: 8-70% depending upon organism and rapidity of treatment
• Disfigurement commonWright, 2016 376
Necrotizing Fasciitis
• Symptoms– Usually occurs after surgery, traumatic wounds,
injection sites, cutaneous sores
– Generalized body aches, fever, irritability
– Key: Red area of skin that is severely painful (It is out of proportion to findings)
– Leg is most common location
• Physical Examination Findings– 1st appears as local area of redness that looks
like cellulitisWright, 2016 377
Necrotizing Fasciitis
• Physical Examination Findings– Tender
– Bullae with purulent center which ruptures quickly
– Black eschar appears and the pain decreases
– Systemic symptoms begin
Wright, 2016 378
64
Necrotizing Fasciitis
Bullae: Below these lesions is necrotic tissueWright, 2016 379
Necrotizing Fasciitis
• Plan
–Diagnosis: Culture of wounds, blood cultures, biopsy of area, CBC with differential, urinalysis
–Therapeutic: HOSPITAL ADMISSION
–Educational: Good wound hygiene
Wright, 2016 380
Stevens-Johnson Syndrome• Distinct, acute hypersensitivity syndrome
• Many causes: Drugs, bacteria, viruses, foods, immunizations
• Also known as Bullous Erythema Multiforme
• Stevens-Johnson Syndrome is thought to represent the most severe of the erythema multiforme spectrum
• Two stages– Prodrome which lasts 1-14 days
– 2nd stage: mucosal involvement where at least 2 mucousal surfaces are involved (oral, conjunctival, urethral)
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Stevens-Johnson Syndrome
• Mortality: 5-25%
• Long-term complications are common
• Face almost always involved and mouth always involved
• Entire course: 3-4 weeks
• Most common in children aged 2 - 10
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Stevens-Johnson Syndrome
• Symptoms– Constitutional symptoms such as fever, headache,
sore throat, nausea, vomiting, chest pain, and cough
• Physical Examination Findings– Vesicles that are extensive and hemorrhagic
– Bullae rupture leaving ulcerations which are covered with membranes
– Leave large areas of necrosis and skin peels
– Lesions on the conjunctivaWright, 2016 383
Erythema Multiforme
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Erythema Multiforme
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Stevens-Johnson Syndrome
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Stevens-Johnson Syndrome
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Stevens-Johnson Syndrome
• Plan– Must rule-out staphylococcal scalded skin
syndrome
– Therapeutic: HOSPITALIZATION with early opthamological evaluation
– Steroids are controversial
– Others in family may be genetically susceptible
– Never take these medications again
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Wright, 2016