Peds L11: Dz of Childhood - Infectious dz and derm

Otitis Externa

inflammation of the external auditory canal

Otitis Externa: mc cause

Pseudomonas aeruginosa

Otitis Externa: risk factors (4)

swimming, trauma, occlusive devices, allergic contact dermatitis

Clin pres of otitis externa (4)

- Otalgia, pruritis, discharge

- hearing loss

- Erythema and edema of ear canal

- purulent exudate

- pain with manipulation of the auricle and tragus

- TM may be erythematous or obstructed

- TM moves normally with pneumatic otoscopy

If a child has otorrhea, always consider

Foreign body

Mild to moderate otitis externa tx

Topical drops

- Neomycin/polymyxin B or FQ (Ciprofloxacin)

+/- Corticosteroid

Severe Otitis externa tx

topical and PO abx (amox clav)

If significant edema with otitis externa tx

ear wick

If TM is NOT intact, what to tx otitis externa with

Fluoroquinolone drops (cipro)

Avoid ___ with otitis externa

submerging in water

Pain mgnt for otitis externa (2)

NSAIDs, acetaminophin

Complications of otitis externa (2)

cellulitis, malignant external otitis

What is serous otitis

presence of middle ear fluid without signs of acute infx - OM with effusion

RFs fro serous otitis (8)

- FHx of OM

- Bottle feeding

- M>F

- Daycare/school

- Adenoidal hypertrophy

- Tobacco smoke exposure

- Obesity

- Facial anomalies (cleft palate)

Clin pres serous otitis

- Often asymptomatic

- HL, fullness in ear, tinnitus and balance problems

- TM dull and hypomobile, can have air bubbles and conductive hearing loss

Dx serous otitis (2)

clinical

Pneumatic otoscopy

Tx of serous otitis

Watchful waiting - clinical f/u in 3 months (usually resolves spontaneously

Serous Otitis: If at risk for speech, language or learning issues

refer to ENT if persists ≥ 4 weeks

if refractory or persistent hearing issues tx of serous otitis

refer to ENT for tympanostomy tube

If structural damage to the TM or middle ear with serous otitis

refer to ENT

The most common pediatric infection for which abx are prescribed in the US

acute otitis media

MC population for acute otitis media

Time of year

- Kids < 5 yo

- Peak between 6 mo-12 mo

- Late winter/early spring

Organisms mc for acute otitis media (3)

- Streptococcus pneumoniae

- Haemophilus influenzae

- Moraxella catarrhalis

Clin pres acute otitis media

- Typically U/L otalgia

- decreased or muffled hearing

- fever

- pulling ears, rubbing ears, fussiness, poor feeding

- Bulging and erythematous TM

- reduced mobility of TM

- partial/complete opacification of TM, bullae

Otitis Media dx

Clinical and pneumatic otoscopy

dx for otitis media if child appears toxic, immunocomp, or failed courses of abx

Tympanocentesis

When is amox clav acid preferred for acute otitis media (3)

- if Beta lactam in past 30 days

- Purulent conjunctivitis

- Recurrent OM unresponsive to amox

ABX for high risk individuals for acute otitis media - who is high risk (4)

- < 6 mo

- Immunocompromised

- Toxic appearing

- Craniofacial abnormalities

DO NOT wait to tx

ABX for Otitis media acute

Amoxicillin 90 mg/kg per day divided into 2 doses

Otitis media acute tx duration:

10 days

Otitis media acute tx duration: 5-7 days if ≥2yo, if TM intact, and no recurrent AOM

5-7 days

Otitis media acute: when should you recheck

Recheck if no better in 2-3 days

When to refer to ENT for AOM (4)

- Unable to visualize the TM

- if ≥ 3 episodes of AOM within 6mo

- ≥ 4 episodes in 12 months

- If sxs worsen or fail to improve despite appropriate therapy

If recurrent complications of AOM: can cause what and lead to what

Conductive HL --> Speech and language problems

Prevention of AOM (2)

breast feeding

Smoke free home

MCC of pharyngitis

viral

Most common bacterial cause of acute pharyngitis

Streptococcus pyogenes (Group A beta-hemolytic streptococcus)

Viruses mc causing viral pharyngitis (3)

- Adenoviruses

- Rhinoviruses

- Coronaviruses

Clin pres viral pharyngitis (4)

- Upper resp sxs - fatigue, nasal, congestion, and cough

- Possible fever (typ low grade)

- Pharynx with erythema and tonsillar edema +/- exudate

- +/- Cervical LAD

Tx for viral pharyngitis

- No effective antiviral therapies, self limiting

- Supportive care - warm saltwater gargles, lozenges, NSAIDs, fluids, rest

Complications of viral pharyngitis (3)

OM

serous om

ET dysfunction

Cause of infectious mononucleosis

Peak incidence age

- EBV

- In adolescents and young adults

Transmission of infectious mononucleosis

Direct contact - body fluids, especially saliva

infectious mononucleosis Triad

fever, tonsillar pharyngitis, and LAD

Clin pres infectious mononucleosis (7)

- fever

- tonsillar pharyngitis

- B/L posterior cervical and posterior auricular LAD

- Malaise, HA, and low grade fever

- Fatigue

- Splenomegaly

- Generalized maculopapular, urticarial, or petechial rash

Work up for infectious mono (4)

- Heterophile agglutination test (monospot) EBV titers

- CBC with diff - elevated WBC, lymphocytosis

- rule out strep

- +/- elevated LFTs

Dx of infectious mono

Positive monospot or EBC titers

When can athletes generally return to sports if they have infectious mono

4 weeks from sx onset

Tx for infectious mono

supportive - NSAIDs or tylenol, fluids, rest

infectious mono complication

splenic rupture and death

Causes of bacterial pharyngitis

Streptococcus pyogenes (Group A beta-hemolytic Strep)

= the most common bacterial cause

Clin pres bacterial pharyngitis for < 3 yo toddler vs infant

- do not have classic sxs

- infants - fussiness, dec appetite, low grade fever

- Toddler - nasal congestion, low grade fever, tender anterior cervical lymph nodes

Clin pres bacterial pharyngitis for >3 yo

- Abrupt onset

- Sore throat - enlarged erythematous tonsils

- enlarged tender anterior cervical LAD

- palatal petechiae

- inflamed uvula

- Fevere

- HA/ABD PAIN/N/V

- Scarlatiniform rash and strawberry tongue

Who to test for bacterial pharyngitis

≥3 and acute tonsillopharyngitis (erythema, edema, and/or exudate) or scarlatiniform rash

Bacterial Pharyngitis: what criteria should you use for adults?

Centor Criteria

How to dx bacterial pharyngitis

Rapid antigen detection test or rapid molecular assays

If RADT negative -> throat culture

Tx for bacterial pharyngitis (3)

- Amoxicillin (50 mg/kg/day x 10 days)

- Penicillin V potassium, IM penicillin G Benzathine

- Fluids, soft diet, NSAIDs or Tylenol

- If old enough -> Warm saltwater gargles, lozenges (choking hazard)

Non supportive complications of bacterial pharyngitis (3)

Acute rheumatic fever, poststreptococcal glomerulonephritis, PANDAS

Supportive complications of bacterial pharyngitis (5)

Necrotizing fasciitis, bacteremia, peritonsillar abscess or cellulitis, OM, sinusitis

Croup

Inflammation in the larynx and subglottic airway

Croup: mc caus

Parainfluenza

Croup:

What time is it MC

Age MC

- FALL AND WINTER

- ≤6 yo -> highest rates in 6 mo to 3 yo

Clin pres for croup

- Nasal d/c, congestion, coryza

- Often dec PO intake

- 12-48 hours later fever

- hoarseness, barking cough

- Inspiratory stridor: significant upper airway obstruction -> minimal pharyngitis

- Can progress to resp distress

Croup Workup

- rapid assessment of appearance, virals, O2, airway stability, and mental status

- hydration status

- r/o other causes of airway obstruction

Croup: what to do if dx is unclear

Perform imaging - XR

XR croup

steeple sign

Westly croup score for mild croup

Score ≤2

barking cough, hoarse cry, no stridor at rest (although stridor may be present when upset or crying), and either no or only mild chest wall/subcostal retractions

Westly croup score for moderate croup

Score 3-7

Stridor at rest. They have at least mild retractions and may have other mild to moderate symptoms or signs of respiratory distress

Westly croup score for severe croup

Score ≥8

Significant stridor at rest. They have severe retractions (including indrawing of the sternum) and other signs of significant distress. They may appear anxious, agitated, or pale and fatigued.

Croup score for impending resp failure

≥12

for croup and racemic epi given, how long to observe in er for

3-4 hours

Complications of croup (2)

resp distress

pneumonia

Tx for croup with scores:

Single dose dexamethasone

Causative organism for pertussis (whooping cough)

Infant age

Peaks ___

Bordetella pertussis

Infants < 12 mo

Peaks in summer and fall

Classic triad for pertussis is

- Paroxysms of coughing

- inspiratory whoop

- posttussive vomiting

Catarrhal stage of sxs pertussis

- Viral URI (cough and coryza) x 1-2 weeks

- Fever uncommon

Paroxysmal stage sxs of pertussis (5)

- Coughing spells inc in severity x 2-8 weeks

- Distinctive cough -> long series of cough

- Worse at night

- Whoop follows the coughing attack, forced inspiratory effort

- Posttussive vomiting

Convalescent stage of pertussis

Cough subsides over several weeks to months

dx of pertussis

Clinical

Usually clinical suspicion + laboratory confirmation (PCR and bacterial cx)

Pertussis clinical dx

An acute cough illness of ≥2 weeks and at least one of the following pertussis-associated symptoms:

- Paroxysms of coughing

- Inspiratory whoop

- Post tussive vomiting

- Apnea, with or without cyanosis

OR

An acute cough illness of any duration, with at least one of the above pertussis-associated symptoms, and contact with a laboratory-confirmed case

Tx for pertussis

- Supportive, fluids, avoid triggers

- Azithromycin 10mg/kg daily x 5 days

- Alternatives- erythromycin (if >1 month), clarithromycin (if >1 mo), TMP-SMX (If >2 month)

Is pertussis reportable

yes

When to admit for pertussis (6)

-

Prevention of pertussis

Vaccination! (Tdap or Dtap)

Post exposure antibiotic prophylaxis- all household and close contacts, even if fully immunized

Leading cause of hospitalization in infants

Bronchiolitis

Bronchiolitis

Dz of small bronchioles with inc mucus production and occasional bronchospasm that can lead to airway obstruction

Bronchiolitis mc cause

Respiratory Syncytial Virus (RSV)

Age for bronchiolitis and peak

Time of year

-

clin pres bronchiolitis (4)

- URI sx- fever, congestion (usually thick secretions), and cough

- Lower resp infection 2-3 days later

- Peaks on days 3-5- then improves

- Worsening cough, irritability, wheezing or noisy breathing and respiratory distress

dx for bronchiolitis

Clinical

CXR if not clear

Tx for bronchiolitis

- Supportive

- Nasal suction, antipyretics, fluids

Tx for bronchiolitis: if respiratory distress, hypoxemia, apnea, unable to tolerate PO, or concern about care at home/FU

- ADMIT

- Fluids, supplemental O2

RSV prevention (2)

- annual flu vaccine for everyone ≥6mo

- hand and respiratory hygiene

RSV prevention: Maternal RSV Vaccine give

32-36wks pregnant between september-january

RSV prevention Antibodies

Nirsevimab or clesrovimab

RSV prevention if

give to infant whose mother did not receive the maternal vaccine

RSV prevention if 8-19mo (second season)

Nirsevimab only for high risk children

RSV: Second season high risk Criteria (8)

- born < 32wks

- chronic lung dz of prematurity

- congenital heart dz

- severe immunocompromise

- CF

- anatomic pulmonary or neuromuscular impairing airway clearance

- down syndrome

- american indian/alaska native

Viruses

S. pneumoniae, H. influenzae type b (Hib), nontypeable H. influenzae, Moraxella catarrhalis, S. aureus, S. pyogenes, and atypical bacteria