2 Peds Respiratory infections
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| Young children and fever | A child under 3 months of age with a fever > 101° has a potentially life-threatening illness and requires immediate, thorough, aggressive evaluation and treatment.
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| White counts in kids | nl: 4000-14000, and have more lymphocytes than granulocytes (this switches as they get older)
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| 50% of URIs are | colds (aka viral rhinitis). Kids have lots of colds: 3-8 episodes per year. Rhinoviruses (1O0 serotypes), Coronaviruses, Parainfluenza, respiratory syncytial, adenovirus, influenza, enterovirus, human metapneumovirus
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| The common cold transmission | children are the main reservoir and bring into the home. Routes: hand contact of contaminated objects, inhalation of airborne droplets. Incubation period (2-5 days) but last as long as 8 days
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| Allergic Rhinitis | difficult to distinguish from a recurrent cold; general feeling is that children <2 can't get allergic rhinitis. Family hx of atopy is a clue for allergic rhinitis
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| Differential Diagnosis of the common cold | Pharyngitis, Purulent Rhinitis, Sinusitis, Allergic Rhinitis
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| PE of the common cold | Vital signs, HEENT, Lungs and Heart.
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| Tx and management of the common cold | saline nose drops, nasal bulb suction device, cool mist humidification of the air, vaporizer, maintain hydration, elevate head of teh bed, saline gargles or lozenges for older children,...
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| Tx and management of the common cold continued | Antipyretics (acetaminophen and ibuprofen are different and both can be used in kids>6mo. Decongestants: oral- pseuudoephidrine or phenylephrine. Topical: phenylephrine or oxymetazoline (children over age 2). Cough suppressants (dextromethorphan)
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| In tx children with the common cold, there is no role for | antihistamines
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| Tx length with oxymetazoline | afrin, don't use for more than 3 days, b/c then you will get rebound. (only in kids>2 yo)
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| Prevention of the common cold | handwashing, avoidance not practical, no role for multivitamins, vitamin C in pediatric populations. Breastfeeding may be protective.
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| Bacterial secondary infections most common | otitis media, sinusitis, adenitis, pneumonia, bronchitis
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| A syndrome in young infants associated with a persistent mucopurulent nasal discharge and an irregular fever | Purulent Rhinitis. Group A streptococcus and Streptococcus pneumoniae are frequent causative agents
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| Pharyngitis bacterial presentation (more often in children 5-10 years of age during the winter months. A scarletinea rash may be apparent) | Sudden onset of illness, with sore throat, fever, headache and abdominal pain; sore throat may be minor complaint or absent. Often a lack of other respiratory sx. PE varied: oropharynx may be beefy red, petechiae may be present. ADENOPATHY.
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| Complications of Streptococcal Pharyngitis (will self resolve, but we treat with abx due to the possible complications) | Suppurative: peritonsilar cellulitis or abscess, otitis media, sinusitis, ant cervical lymphadenitis, septicemia. Non-Suppurative: rheumatic fever, glomerulonephritis
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| Diagnosis of Group A Strep Pharyngitis | Throat culture and rapid antigen detection test. Rapid strep tests are specific but lack sensitivity (no false positives, but quite a few false negatives)
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| Tx for Group A Strep Pharyngitis | Penicillin 10 days or 1xIM, amoxicillin (tastes better than penicillin, PCN allergy: cephalexin or erythromycin). Clindamycin for tx failure
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| When can kids with Group A Strep Pharyngitis return to school? | after 24 hours of treatment
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| Other bacterial Causes of Pharyngitis | Corynebacterium diphtheriae (grey pseudo membrane), N. gonorrhea (child abuse), N. meningitidis, groups C and G streptococci, Chlamydia, Mycoplasma pneumoniae (most common after GAS)
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| Infectious mono classic presentation (a type of viral pharyngitis) | exudative tonsilitis. Caused by Epstein Barr Virus. Other sx: posterior cervical adenitis, fever, enlarged liver or spleen. Atypical lymphocytosis and a positive monospot. Monospot frequentlk neg. in kids <5.
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| Other causes of viral pharyngitis | Herpetic gingivostomatitis; aphthous stomatitis,Herpangina, lymphonodular pharyngitis, hand foot and mouth disease (enteroviral disease)Pharyngoconjunctival fever (adenovirus), CMV, parainfluenza, RSV, influenza, rhinovirus
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| large single ulcer should make you think of | herpes etiology. Use a herpes med, short course of acyclovir. Herpes tends to make pts febrile, systemic malaise
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| Disease that looks just like Strep Pharnygitis | Pharyngoconjunctival fever (adenovirus). Think summer swimming pool
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| Inflammation of the paranasal sinuses; < 30 days in duration | Rhinosinusitis
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| Sphenoid sinuses are not fully developed until | 7-8 years. Maxillary and ethmoid sinuses fully formed at birth. Frontal sinuses not fully developed until early teens.
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| Pathophysiology of rhinosinusitis | Each sinus is drained via ostium which empties into a meatus. Obstruction of the osteomeatal complex is the usual trigger for sinusitis.
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| Predisposing Factors to Rhinosinusitis: Foreign body, Systemic: immune deficiency, cystic fibrosis, immotile cilia syndrome. | Infectious: URI, dental infxns. Inflammatory: allergic rhinitis, Vasomotor rhinitis, allergical fungal sinusitis, GERD. Anatomic: nasal polyps, dev. septum, cleft palate, adenoidal hypertrophy.
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| Children Presentation of Rhinosinusitis | >/= days of nasal congestion, purulent nasal drainage, and or persistent cough. Or Abrupt onset with fever>101, facial pain, and purulent nasal drainage.
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| Dx of Rhinosinusitis | Clinical, Sinus x-rays, CT scan
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| Bacterial pathogens of Acute rhinosinusitis | Strep pneumo (45%), H. influenza (25%), Moraxella catarrhalis (20%)
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| Tx of Rhinosinusitis | 10-14 days. Mild to moderate dz: Amoxicillin. PCN allergy: second or third generation cephalosporin OR macrolide. Severe dz and or risk factors: Augmentin, clarithromycin, azithromycin, Cephalosporins. Topical/oral decong. nasal irrig. nasal steroids
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| complications of Rhinosinusitis | Orbital/Periorbital cellulitis (commom presentation/complication of ethmoid sinusitis). Intracranial: subdural empyema, dural sinus thrombosis, brain abscess, osteomyelitis (Pott's puffy tumor)
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| 2nd or 3rd generation cephalosporings | vary greatly in how well they cover strep pneumoniae. Good ones are: Cefprozil, cefuroxime, cefdinir
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| frontal osteomyelitis secondary to frontal sinusitis | Pott's Puffy Tumor. tx is surgical drainage and IV abx therapy
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| Rhinosinusitis: Indications for referral | need for surgical drainage, need for polypectomy, recurrent sinusitis (especially with the exacerbation of asthma), isolation of rare or resistant microbe as etiology, intracranial or orbital complications, suspected immunodeficiency
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| Recurrent Rhinosinusitis | infections clears with antibiotic therapy but recurs with subsequent URIs or when tx is withdrawn
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| Chronic Rhinosinusitis | prolonged symptoms, but no complications. May need longer tx: 21 days Augmentin
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| Bacterial pathogens in chronic sinusitis | L-hemolytic streptococci, Staphylococcus aureus, anaerobes. Evaluation by an allergist and an otolaryngologist may be useful in determining the underlying causes
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| The most common predisposing factor to rhinosinusitis | URI
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| Peak incidence of Otitis Media | 6months and 3 years of age (most occur between 6-12 months). Second peak at 5 years. More common in: boys, formula fed infants, winter months, bottle feeding
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| Risk factors for AOM continued | return
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| Etiology of Otitis Media | return
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| Clinical presentation fo Otitis Media | rapid onset and very irritable. fever, pulling at ears, often follows URI. Bulging, erythematous, immobile TM. TM may rupture spontaneously. if associated with conjunctivitis, think of H. influenza as likely etiologic agent
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| Recumbent positioning in kids with otitis media | Standing up or upright feels better. Laying flat makes the pressure feel greater. So prop kids up a bit.
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| Tx of Otitis Media | conservative approach now recommeded for afebrile children>/=2 years. (80% clear without abx). Oral abx for febrile children and <2 yo. Children <2 are at increased risk for tx failure, hearing loss.
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| Risk factors for PRSP (PCN resistant strep pneumo) in AOM (know which cephalosporins cover strep pneumo) | Recurrent tx with beta-lactam abx, recurrent AOM, day care attendance, winter season, age younger than 2 years
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| Abx tx in AOM | All kids get high dose. Amoxicillin is now considered standard (80-90mg/kg/d in two divided doses; inhibits 98% of all pneumococcal isolates). Augmentin (use ES suspension 600mg/5ml). Zithromax for PCN allergic
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| If amoxicillin followed by observation of AOM fails after 72 hours, then | start Augmentin high dose. If HD Augmentin fails after 72 hours, use IM ceftriaxone x 3 days.
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| Surgical Tx of Otitis Media | tympanocentesis; myringotomy/tympanostomy tubes indicated for: bilateral effusion for a total of 3 months AND a bilateral hearing deficiency. Use of pneumococcal conjugate vaccine has decreased incidence of surgery for tube placement by 25%
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| Complications of otitis media | return
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| Kids with Influenza | tend to have more GI sx than adults do. N/V
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| Clinical manifestation of Influenza includes: | return
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| Complications of Influenza | pneumonia (bacterial or viral), Myositis, myocarditis, pericarditis, aseptic meningitis, encephalitis, Reye's syndrome, Guillain-barre syndrome
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| Dx of Influenza | epidemiologic, virus isolation or antigen detection, serologic
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| Treatment for Influenza A | Amantadine, Rimantadine (fewer AEs but FDA approved only for prevention), Newer drugs: tamiflu now approved for children>1year
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| Prevention of Influenzae | two doses separated by four weeks for the first administration in a kid. Now recommended for all kids 6-59months.
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| 3 most common lower respiratory infections | bronchiolitis, laryngeotracheobronchitis (croup)
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| >/= 10-14 duration of acute nasal congestion and sinusitis without improvement suggests | bacterial sinusitis (viral should resolve within 10 days)
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| Most common complication of frontal sinusitis | pott puffy tumor. Intracranial extension leads to meingitis and to epidural, subdural, and brain abscesses
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| Most common maxillary complication | cellulitis of the cheek
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| Clindamycin is used for what etiologic agent of rhinosinusitis? | S. pneumoniae
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| Supportive Tx for Viral rhinosinusitis | pain medication, humidified air, saline nose drops, cough suppressants
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| PE findings suggestive of GAS pharyngitis | anterior cervical nodes, palatal petechiae, a beefy-red uvula, and a tonsillar exudate
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| Most common etiologic cause of Viral Croup(after this agent, consider influenza, RSV and human metapneumovirus) | Parainfluenza virus serotypes. PIV types 1 and 2 commonly cause outbreaks of croup during the Fall. PIV type 3 occurs throughout the year.
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| Laryngotracheobronchitis | inflammation of the subglottic trachea. Most common clinical manifestation of acute upper airway obstruction. Sx: stridor (intermittent at first, but increase as obstruction increases), hoarseness, "barking seal" cough, low grade fever, sx typ worse pm
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| Croup epidemiology | More common in children ages 6months-3 years. More common in winter months. Males>Females. recurrent infections common. Family hx plays a role
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| PE findings of Croup | barking cough, stridor, fever usually absent or low grade, drooling, air hunger, retractions, cyanosis, rales, ronchi, wheezing, elevated RR, steeple sign on x-ray
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| Tx of Viral Croup | mild (barking cough but no stridor at rest)=supportive therapy with oral hydration. Pts with stridor at rest should get oxygen and epinephrine, and glucocorticoids (dexamethasone)
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| Laryngotracheobronchitis (Croup) definition | inflammation of the subglottic trachea
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| Bronchiolitis Definition | A syndrome of illness related to infection of the smaller bronchi and bronchioles. Results from inflammatory obstruction of these airways. Occurs both sporadically and epidemically
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| Typical presentation of bronchiolitits | acute onset of tachypnea, cough, rhinorrhea, and expiratory wheezing. Hyper-resonance to percussion, a prolonged expiratory phase
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| Epidemiology of bronchiolitis | generally in children less than 2 with a peak at 6 months. More common in winter. Males>females. Chilren with underlying cardiopulmonary dz or immunodeficiency at higher risk
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| Etiology of Bronchiolitis | Most common is RSV. Human metapneumovirus (in <2 yo clinically indistinguishable from RSV) and Parainfluenza, adenovirus and a few others.
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| Clinical findings with Bronchiolitis in addition to wheezing, retractions, tachypnea and rales | underlying URI, sometimes conjunctivitis and otitis. low grade fever. Young babies maybe have apneic spells. X-ray may show hyperinflation, atelectasis and infiltrates.
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| How can you confirm the etiologic agent of bronchiolitis? | antigen testing or culture of nasal secretion
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| Tx for Bronchiolitis | supportive strategies including frequent suctioning and adequate fluids. If hypoxia is present, tx with oxygen. Bronchdilators and corticosteroids may be used in select children who respond
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| Bronchiolitis: in high risk infants, what should be given as prophylaxis? | Synagis or RSV immune globulin.
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| Differential diagnosis for bronchiolitis | asthma, fb
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| Pneumonia definition | A syndrome of illness related to infection of the smaller airways or alveoli
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| Sx of Pneumonia | increased RR, decreased breath sounds, dullness to percussion, rales or fine crackles, fever (high in bacterial etiology),
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| Etiologies of pneumonia are | age dependent. Viruses are the most common offending agents, particularly in kids <5 years old
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| Risk factors for pneumonia | congenital heart and/or lung disease, cystic fibrosis, asthma, sickle cell disease, immunodeficiency syndromes
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| Viral causes of pneumonia in children | RSV, PIVs, Influenza, adenovirus. In neonates, consider: CMV, Herpes, rubella
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| Distinguishing viral from bacterial pneumonia: "severity of dz, severity of fever, radiographic findings, and the characteristics of cough or lung sounds do not reliably differentiate viral from bacterial pneumonias". Both can coexist | However, substantial pleural effusions, pneumatoceles, abscessses, lobar consolidation with lobar volume expansion, elevated neutrophil counts and "round" pneumonias are generally INCONSISTENT with viral disease
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| What frequently precedes lower respiratory diseases like pneumonia? | upper respiratory disease
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| viral vs. bacterial pneumonia | viral may show more perihilar streaking on CXR, whereas bacterial may show more consolidation. Elevated neutrophil count is more likely bacterial than viral.
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| Etiology of bacterial pneumonia in kids <1month of age | Children under 2 weeks of age are somewhat more likely to have bacterial etiology. Group B Strep is most common. Also: S. aureus, gram negative enteric bacilli, T. pallidum, Listeria
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| Most likely bacterial cause of pneumonia between age of 1month and 5 years | Streptococcus pneumoniae. Other etiologies: H. influenzae, GAS, S. aureus, Mycoplasma pneumoniae, Chlamydophila pneumoniae. At 2-4 also consider Chlaymdia trachomatis from vaginal birth
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| Most common cause of Bacterial Pneumonia in kids/people >5 years old | Mycoplasma pneumoniae. Strep pneumoniae and Chlamydophila can also cause pneumoniae in this age group. Consider M. tuberculosis in all ped pts especially immigrants. Plus pertussis.
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| Cause of bacterial pneumonia in immunocompromised kids | Pneumocystis carinii (jiroveci)
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| Bacterial Pneumonia presentation | rapid onset of illness with cough, dyspnea, tachypnea, grunting respirations and retractions. Often toxic appearing with a temp>39C (but can appear well)
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| Diagnostic findings in Bacterial Pneumonia | CXR - segmental infiltrates, atelectasis and sometimes pleural effusions. Empyema may resuult. WBC may be elevated with a predominance of polymorphonuclear cells. Blood cultures are positive in 10-30% of children with a bacterial pneumonia
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| Viral Pneumonia presentation | Chilren have little toxicity and generally mild temp elevation. PE: tachypnea, retractions, nasal flaring, and use of accessory muscles. Auscultation reveals diffuse rales and wheezing. CXR: diffuse interstitial infiltrates and hyperinflation
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| Tx of viral pneumonia | supportive. Pulse oximeter may be helpful, respiratory support as needed. Depending on etiology: nebulized albuterol, ipatropium or epinephrine +/- steroids. Amantadine or rimantadine may be used w/ primary influenza A pneumonia
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| What is the role of Clarithromycine and Azithromycin in Pneumonia? | Covers mycoplasma and chlamydia. (amoxicillin is used to cover the strep; avalox covers both, but you can't give Flouroquinolones to kids less than 16 yo).
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| Most common infectious causes associated with runny nose | Viral URIs (rhinovirus, coronavirus, RSV), Sinusitis or purulent rhinorrhea (s.pneumoniae, H. flu, M. cat). Non-infectious: allergic rhinitis, irritants, anatomic problems. If unilateral, consider fb
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| Sudden onset of fever with sore throat, headache and abdominal pain in the absence of URI symptoms suggest | streptococcal pharyngitis. May be accompanied by the rash of scarlet fever caused by erythrogenic-toxin producing strains of GAS. Some consider this diagnostic
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| Typical features of Infectious mononucleosis | Prolonged fever, exudative pharyngitis, generalized adenopathy, hepatosplenogmegaly, fatigue, malaise
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| Etiologic agent of IM | Epstein Barr Virus. Spreads via saliva (asymptomatic carriers and from recently ill pts who shed the virus for many months) Adolescents may be infected through sexual activity. Also transmitted through blood tranfusion and organ transplantation
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| Young children with IM | either no sx or a mild nonspecific febrile illness. More typical features as the age of the patient increases
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| Major complaint in IM | pharyngitis. Posterior and anterior cervical nodes are almost always enlarged.
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| Lab procedures utilized in the diagnosis of IM | Peripheral blood (atypical leukocytosis), Heterophil Antibodies (more in older pts than younger..may be present for 12 months after), Anti-EBV antibodies (helpful in kids when heterophil antibodies are -), EBV PCR (#1 method for CNS and ocular infxn)
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| Tx for IM | Bedrest, acetominophen (for fever), corticosteroids (for pharyngitis), antivirals
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