Respiratory

What is epiglottis and why is it important in children?

Flap-like structure located at base of tung; covers airway to allow food to enter GI

• If it becomes swollen due to inflammation → airway obstruction → resp. failure → cardiopulmonary arrest

Pediatric vs. Adult Respiratory Anatomy (except upper resp. structures):

Nose breathing:

• Obligatory around 2-6 months

• Nasal congestion → issues breathing → resp distress

Chest Wall:

• More circular/rounded

• Horizontal ribs + weak/immature ICS muscles → ^ WOB → resp. fatigue

Oral cavity & tongue:

• Larger tongue → ^ r/x for airway obstruction

• Higher laryngeal position

• Adults:

  • More proportional tongue & lower airway structures

Nasal cavities:

• Narrow passages

  • Even minimal swelling can pose distress r/x

• Rapidly growth during first 5 years

• Adults:

  • Wider & Wedge-shaped

Trachea:

• Short + Narrow + Less supported

• More prone to collapse

• Small edema/inflammation can also ^ airway resistance

Alveoli:

• At birth: 17-71 mi

• 6 months: 2x

• 12 months: 3x

• 2-3 years: multiplication stops

• Adult: 200-600 million

• Growth allows ^ surface area → ^ gas exchange

Sinuses:

• At birth, only 2 sinus groups

  • Ethmoid + Maxillary

  • v resistance when breathing via nose

• Later childhood (5-6 years), others develop

  • Frontal + Sphenoid

• Adults: have all 4

  • ^ r/x of nasal congestion

Head & Neck:

• Large head + short neck → harder to maintain & open airway with normal neck positioning → ^ upper ubstruction r/x

Pediatric vs. Adult Respiratory Anatomy (upper resp. structures):

Peds:

• Pharynx → shorter

• Adenoids & Tonsils → enlarged till 5-7 years → gradual atrophy

• Larynx → more anterior

• Epiglottis → Higher & MORE horizontal

  • due to larynx location

• MORE prone to resp. failure & hospitalizations

  • E.g. influenza

Adult:

• Lymphatic structures have atrophied

• Larynx → posterior

• Epiglottis → lower

• Cricoid cartialge: located now at C6 level

• Airway: larger & more supported

Cricoid Cartilage Levels

Age	Cricoid cartilage level
Up to 2 years	C4
Around 6 years	C5
Adult	C6

How are s/s like in ped patient’s w/reactive airway disease or prominent wheezing as they grow?

As child grows: airway diameter ^ → resistance v → improved airflow

• Decreases in severity & s/s

Different resp. physiology of peds vs adults:

Immature respiratory control:

• Neonates/preterm infants have immature systems → ^ r/x of

  • Apnea, brady/tachypnea

Increased Metabolic Demand:

• require more o2 → ^ r/x of hypoxia due to combination with immature system too

Diaphragmatic breathing:

• Older children + Adults:

  • Utilize effort w/Diaphragms & ICS muscles

• Neonates/infants:

  • Primary RELY on Diaphragm due to weak ICS muscles & round chest wall

Upper vs Lower Airway RIs:

Upper Respiratory Tract	Lower Respiratory Tract
Above the trachea	Trachea and structures below it
Nasal passages, pharynx, larynx, etc.	Trachea, bronchi, bronchioles, lungs, alveoli
URIs are the most common respiratory diseases in children	Can produce more significant lower-airway disease

How are most pediatric ARIs spread? What is the average incubation + Course of illness?

Most spread via contact:

• Infected person → surface → child touches it → touches eye/nose → organism enters

Droplet:

• Either Viruses/Bacteria/Fungi → infection → inflammation → swelling + sceretions → drainage + congestion + s/s

Incubation:

• 1-3 days → onset

Lasts around 4-10 days

Pediatric Respiratory Screening & Respiratory Distress signs

Always remember that resp infections can be more severe & quick to deteriorate due to child’s anatomy & developmental stage

• Intercostal retractions:

  • Not used in ventilation due to their immaturity, when child has resp distress → try to use ICS muscles to aid breathing (^ WOB) → tissue between ribs may be pulled inward → retraction

• Breathing A/x:

  • Pattern, Rate, & effort

• Resp distress SIGNS:

  • Nasal flaring: widen to move more air

  • Head bobbing

    • Neck muscles contract to help bring in air

  • ICS retractions

  • Grunting

• Skin color:

  • Hypoxia → Cyanosis

• Auscultation:

  • Wheezing:

    • Suggests swelling & restricted airflow

• Temp + Moisture:

  • Pyreixa: fever/^^^ temp

    • First s/s that parents notice

    • MORE COMMON IN younger children > older children

  • Diaphoresis

Parent/Child Interview for ARIs:

Ask for Duration, Exposure, Previous t/x efforts (did they work?), Medical h/x

• And infant h/x:

  • Birth h/x or prenatal h/x too

ARI Epidemiology:

<2 years = highest incidence (per-child)

School age: higher total # of episodes

Most often viruses

Common in Fall/Winter/Spring:

• Schools returning in session

• Holiday gatherings

• ^ people exposure

• NOT associated w/cold temperature

ARI r/x:

Weakened Immune systems

Spread germs easierly: → more frequent transmission & exposure

• Puts hands in mouth

• Poor cough etiquette

• Poor hygiene

• Lack of disease spreading knowledge

Daycares:

• Sick children may come to daycare → ^ exposure & r/x of viral transmission

Other:

• Low birth weight

• Short gestation

ARI s/s: (mild & severe)

Common:

• Nasal secretions

  • Clear + watery (most common)

  • Purulent as illness progresses

    • Does not ALWAYS mean it is a bacterial infection btw → rule it out first

• Sneezing, Coughing

• Eye drainage, Fatigue, Headache

• Low-grade fever, Epistaxis

Severe:

• Tachypnea, ^ WOB, Wheezing

• Hypoxia, Hypercapnia

• Retractions, Nasal flaring

• v LOC: minimal responses to stimuli

• GI:

  • N/V & Diarrhea

ARI Labs & D/x:

Mild:

• Physical a/x, evaluation & parent h/x → enough to establish a d/x

More severe/uncertain/further testing → more testing done

• Rapid swabs for:

  • Strep infection

  • Influenza A or B

  • RSV, COVID-19

• CBC w/differenial: helps determine which WBC is ^

  • ^ Neutrophils = bacterial

  • ^ Lymphocytes = viral

• Radiology

Hospitalized Patients: Require a more complex & comprehensive d/x

• If c/x is not i/x → differential d/x testing: checks for possible health conditions related to similar s/s that pt has

• Secondary infections may also happen due to compromised immune system

• Example:

  • If RSV infection → child develops s/s of pneumonia → additional d/x testing → check for pneumonia’s severity, type & location

Why is nasal congestion distressing for infants? interventions for it?

Nasal congestion → may have difficulty breathing & sucking at same time → crying because they cannot suck from a bottle

• Sucking is also a comfort measure

  • If impaired → ^ frustration → cries → worsens resp s/s

• Clear nasal passage

ARI communication & vaccine education:

Communication:

• Use language appropriate to developmental level

• Get down on eye level, smile, calm body language, follow through on promises

• Child may respond more strongly to what a RN does vs what they say too

Vaccines:

• Edu to start early due to multiple injections required

  • Start edu in prenatal period

• Immunocompromised pt’s may also be unable to receive certain vaccines

• Influenza & COVID-19 vaccines are important for children w/underlying chronic resp conditions

• Edu that there are no current vaccines that prevent common cold

  • Mainly due to its nature

What to teach child & parent during well-child visits (respiratory-based)?

Educate child when they are healthy

• If ill → v focus ability

• Cover their mouth & nose when sneezing

• Handwashing

Encourage mom to breastfeed

Respiratory at home care:

• Edu should be:

  • Detailed + Specific + Step-by-step + given in writing too

• Should return to hospital if s/s worsen

What is croup?

Not a single disease, but multiple that affect upper & middle airway

• Affects:

  • Larynx, subglottic region, trachea

  • Rarer:

    • Epiglottis

    • bronchi

      • more chest s/s present

• Causes airway swelling → restricts airflow

• Short in duration (2 days)

  • Self-limiting

  • Not ER mostly

Croup Types:

Viral:

• Parainfluenza virus

• Enters nasal passage → pharyngeal → inflammation of lining → laryngeal inflammation → swelling → restricted Upper-airflow → Croup

• Usually follows a respiratory illness and is associated w/fever

  • Starts w/Upper resp s/s

  • Does not repetedly recur AFTER child recovers from a virus

Spasmodic:

• Allergens → Airway edema

• Pattern:

  • Occurs at night, is sudden

  • Mild coryza s/s

  • May happen w/out fever; can recur

  • May resolve before t/x is needed

What is the croup population?

6 months → 3 years

• Males

• Family h/x of croup

• Exposed to resp. infections, smoke

• Smaller airway diameters

• Autumn or Early winter season

Spasmodic croup populaiton:

• Allergy h/x or reccurring night s/s

Croup s/s timeline:

Days 1-2:

• Coryza

• Congestion

Day 3:

• Fever

• Hoarseness

• Barky cough: harsh cough

• Inspiratory stridor

  • Causes by upper airway obstruction

→ If swelling progresses:

• ^ RR, WOB

• Anxiety/Agitation

  • May ^ resp effort/stress → worsens & creates cycle

  • keep child calm

• ICS retractions & prolonged inspiration

SEVERE:

• Stridor during inspiration AND expiration → v Breath sounds → resp failure

• ICS retractions & Hypoxia

• Nasal flaring, bobbing, ^ RR, cyanosis

Assessing a Child With Croup

VS

Also:

• Hydration

• Swallowing, Voice volume, Issues speaking

• Drooling

• Throat pain/discomfort

Acute Epiglottitis and Causes:

Inflammation & swelling of epiglottis → possible obstruction

• Medical emergency

Causes:

• Mostly bacterial

  • Haemophilus influenzae Type B (Hib): Hib vaccine drastically vvv epiglottitis rates

• Unvaccinated, not up to date

• Noninfectious:

  • Smoke, Chemicals

  • Heat, hot food/beverages

  • Inhalation injuries

Classic Epiglottitis Presentation

Child basically looks REALLY sick:

• High fever, severe resp distress

• Drooling

• Dysphagia, throat pain

• Stridor

• Refuses to lie falt → Tripod/orthopneic position

  • Sit upright, lean foward, extend neck, uses arms to support upper body

  • Allow them to remain in this position

• Anxiety

• Cyanosis

What should you always avoid with a children with epiglottitis?

NEVER inspect throat

• Do not:

  • force child to open mouth

  • Use tongue depressor

  • Agitate child

• All of these can trigger laryngeal spasms → complete airway obstruction

Croup vs Epiglottitis D/x:

Croup:

• Clinical presentation + H/x + a/x

• Possibly:

  • x-ray & CBC

Epiglottitis:

• D/x clinically

• Avoid delaying airway management and painful procedures that may trigger spasms

Croup t/x:

Mild-moderate:

• Prednisolone: v immune activity & inflammation

  • A/E:

    • GI distress

    • ^ BG, weight, infection r/x; v bone density & wound healing

    • Poor sleep

  • Interactions:

    • Desmopressin, live rotavirus vaccine

    • Ciprofloxaccin, Ibuprofen/NSAIDs

  • Give in morning and w/food

• Dexamethasone: X neutrophil migration → v inflammation

  • More potent, longer-half life = can be given lower dose & less frequently

  • A/E:

    • Insomnia, Acne, indigestion

    • ^ weight, appetite, N/V

    • Fluid retention

  • Interactions:

    • Birth control pills, Digoxin

    • Bleeding r/x meds:

      • NSAIDs, antiplatelets

  • Give in morning and w/food

Epiglottitis t/x:

AIRWAY:

• Not comfort, d/x, or throat examination

• Suspected → keep child calm → maintain comfort position → airway management → notify ER team

• Gather tracheostomy supplies right away

  • Wherever child goes, bring supplies with

  • RN should always remain w/child

• Avoid child crying or being agitated → spasms → obstruction

• Allow them to choose position of their liking

Home care and Coup prevention:

Home care:

• Use humified air/steam & allow them to breath cool air → v night s/s

• Calm, hydrated

• Avoid smoke exposure

  • Exposure can ^ exacerbation

Prevention:

• Handwashing & cough etiquette

• If children sick, keep at home

  • If hospitalizad, separate from other children

Epiglotitis Prevention:

HiB vaccination

What is Bronchitis?

Inflammation of smaller airways towards end of larger airways

• Pathogen enters → edematous + mucus + narrows → airway irritation → coughs

• Virus/Bacteria/Fungi

What is Bronchiolitis?

Affects smaller airways

• Viral infection → dmged epithelial cells → edema → excess mucus + dmged cells slough off → air cannot reach alveoli → possible alveoli collapse → impaired gas exchange → resp. distress OR hypoxia

Bronchitis r/x:

Influenza, RSV, COVID-19

• Bacterial may also cause, but less common

• If chronic, often due to underlying disease like CF

• GERD may also pose ^ r/x

Bronchiolitis r/x:

Mostly viral

• RSV; children <2 years

• Autumn → Winter; Also early spring

• Cause of MOST hospitalizations of peds pt <5 years

High r/x children:

• Infants <2 years

• Premature infants; v birth weight

• Undelying heart or lung disease

• Immunocompromised

Full-term infants may also be at risk till 12 weeks of age

Bronchitis/Bronchiolitis s/s:

Cough, Fever, ^ RR, wheezing, crackles

• Prolongued expiration

Parents often report child had URI days before w/:

• Coryza & Nasal congestion

Progresses rapidly into:

• Poor breathing, Diminished breath sounds

• Retractions, ^ distress, & hypoxia

• Worsen s/s when child coughs OR cries

  • Try to a/x resp effort before touching child; handling may alter baseline

Key resp. distress s/s relate to this condition

What are children w/Bronchitis/Bronchiolitis at risk for?

Dehydration

• Due to:

  • ^ RR → insensible fluid loss

  • Poor oral intake

• Dry mouth, cracked lips, v Urine output, poor turgor

Bronchitis/Bronchiolitis D/x:

Uncomplicated:

• S/s, O2 sat, h/x, examination

• Chest x-ray not usually done

  • Done when there is a concern for:

    • Pneumonia or other complications

Bronchitis/Bronchiolitis T/x & Care:

Mostly supportive measures: (due to virus t/x not needing antibiotics)

• Hydration

• Fever management:

  • Tylenol/Ibuprofen

  • Avoid excessive clothing

  • Tepid bathing if PRN

• Management of Nasal secretions:

  • Nasal drops + bulb suction/syringe

  • Allows infant to suck and feed → v stress

• O2 if hypoxic (<95%)

• Keep patient calm and avoid too much stimulation; keep parent close

• AVOID SMOKE EXPOSURE; proper etiquettes & sanitation techs

• Encourage play when child improves

What is RSV? Patho + incubation/Shedding period

RNA virus that commonly infects infant & young children; HIGHLY contagious & spreads via direct contact w/resp/nasal or eye secretions

• Droplet may also transmit it

• Can live for hours on surfaces

• Starts nasopharynx → descends to bronchioles & alveoli pneumocytes

  • RSV → bronchiolar inflammation (neutrophil infiltration) + epithelial cell destruction + mucus overproduction + sloughed cells → tiny airway obstruction → occluded → impaired flow + ^ resistance → resp diress & hypoxia

Incubation period: 4-6 days

Shedding period: up to 11 days

RSV r/x:

Fall → Spring

• First 2 months of year too

• tropical areas: rainy seasons ^ r/x

People of ALL ages can become infected

• S/s vary based off:

  • Age, primary/secondary, underlying conditions

Other r/x:

• <6 months

• Premature, low birth weight

• DOWN SYNDROME

• Heart or Lung disease

• 2nd hand smoke

• Immunocompromised

• vvv SDOH

How does reinfection of RSV play a role in immunity?

Most ppl develop some degree of immunity the second time around; BUT:

• RSV does not produce LONG-TERM immunity

  • Still prone to be infected 1+ times

• S/s tho are still less severe than the 1st time

RSV s/s:

Older children may mostly have URI s/s:

• Coryza, cough, congestion

• Conjuctivitis

Lower resp s/s:

• Wheezing/Crackles

• ^ RR, apneic episodes r/x

Severe: May cause a reactive airway

• Bronchospasms + Severe coughing + Hypoxia

What is the gold-standard testing & other d/x for RSV?

Gold-standard is Nasal Secretion sample

• Done via nasal washing or swabbing

  • Swabbing may also help check for other viruses:

    • Rhino/Entero/Adeno/COVID

PCR (Polymerase Chain Reaction): preffered

RADT (Rapid Antigen Detection Test): if PCR unavailable

RSV t/x:

Supportive

• Hydration

• Fever management

• Bulb suctioning

• Infection control (contact + droplets+

  • PPE when suctioning

    • due to splash risks (gloves + gown + eye shields

• If child leaves room → surgical mask on kid

RSV prevention:

Nirsevimab or Clesrovimab may be given to infants as they enter their 1st RSV season or high-risk children(8-19 months) entering their 2nd RSV season

• Check injection site for reaction or signs of Anaphylaxis when administering

How can RSV affect mental-wellbeing of infants?

Same as others; nasal secretions → clogged → crying & stress ^^^

What should you consider for children w/RSV?

Possible developmental delays in trust vs mistrust phase due to prolongued hospitalization

• Incorporate interaction + play + stimulation opportunities

Protecting the Child With RSV

AIRWAY → TRANSMISSION → OXYGEN → FLUIDS

• Oxygen therapy may cause ^ fluid loss or hypothemia → humidification or warm oxygen PRN; titrate PRN too

• if giving IV fluids for hydration, monitor for possible overload

  • Check:

    • Lung sounds, edema, I&Os (weigh diapers), daily weights

RSV Edu:

Teach parents to:

• keep child away from older children, adults, or immunocompromised ppl

• Teach precautions, prevention, and hygiene

• Manage fever, secretions (bulb syringe), hydration, or possible resp distress monitoring

• AVOID smoke exposure

• Child can return to daycare IF:

  • Free of fever AND nasal discharge

• If child is in contagious stage, still incorporate play, but ALONE

  • Provides diversion, v boredom, ^ learning opportunities

Pneumonia:

Infection of lungs which a organism travels to lower structures

• Bronchi → inlammation develops → alveoli → connective tissue & vasculature

HOW PNEUMONIA IS CLASSIFIED

1. Cause/Organism

2. Pattern of lung involvement

Bacterial pattern:

• Lobar

• Bronchial

• Nectrotizing

• Caseating granuloma: focal area or dead cells following infection

  • “cheese”

• Interstitial & Peribronchiolar w/2ndary parenchymal infiltration

Viral patters:

• Interstitial

• Parenchymal

VACCINATION AND PNEUMONIA

Pneumococcal vaccine & Hib vaccine → vvv pediatric pneumonia

• Still less likely to be hospitalized

Pneumonia Types:

Bacterial Pneumonia:

• Bacteria found in nasopharynx are aspirated/inhaled

  • “Streptococcus pneumoniae” most commmon in <few weeks of age

• Aspiration pneumonia: ^ r/x with children w/:

  • v LOC, anesthesia usage, dysphagia

  • Seizure disorders, GERD, substane/ETOH exposure

Viral Pneumonia: most common organism causing this in <5 year olds

• Biggest prevention = handwashing

• Primary Atypical: may not respond to typical ABX

  • Mycoplasma Pneumonia

  • Chlamydia pneumoniae

  • Legionella pneumophillia: “less common”

NEONATAL bacterial/viral/fungal pneumonia:

In newborns <28 days

• Early-onset: w/in 72 hrs of birth

  • aquired from mother

• Late-onset: >72 hrs after birth

  • from community or in hospital (if bebe stayed hospitalized more time than expected)

Bacterial:

• Group B streptococcus (GBS)

• E-coli

Viral:

• Occurs through:

  • Transplacental

    • can cause further problems

  • Perinatal: during birth

  • Postnatal

    • Family members/parents/ppl around

• Herpes simplex, CMV, COVID-19, Entero

Fungal:

• Often w/premature/low birth weight/or steroid use bebes

Early-onset vs Late onset Neonatal pneumonia r/x:

Early-onset

• Premature;low birth weight

• Infection of amniotic sac/fluid

• PROM

• GBS positive in maternal culture

• Mom fever

Late-onset

• Premature; low-birth weight

• Prolongued stay; mechanical vent (long-duration)

• H2-blockers, airway issues

• Neonatal pulmonary disease (severe)

• Neurological impairment → v protection of airway

General r/x for pediatric pneumonia:

• <5 yrs; v SDOH

• Late autum, winte, & early spring

• Larger households,many siblings

• Underlying diseases

Medical r/x:

• Cardiopulmonary, Neuro,GI, Immune issues

• v LOC

Bacterial Pneumonia s/s:

May have subtle s/s:

• Fever or Cough

  • Cough may not be prominent due to infants having LESS cough receptors than adults

    • cough may mean Signifitcant infection is occuring

• ^ RR & WOB

Neonatal pneumonia s/s: general + early/late-onset distinctions

Poor feeding, fussiness, issues consoling, resp. distress, sleepiness

• May have pneumonia even w/out cough or abnormal sounds

Early-onset: May occur at birth or soon after

• Resp distress, apnea, irregular temp

• Poor perfusion → metabolic acidosis

• CNS suppression

• Sepsis s/s

Late-onset: may start of as asymptomatic → later s/s

• Apnea, ^RR, Respiratory distress

• Poor feeding, emesis, distended abd, jaundice

• ^ HR, v BP

Atypical pneumonia s/s:

Mycoplasma + Chlamydia general: Abrupt presentations

• Headaches, Fever

• Conjuctivitis, Photophobia

• Pharyngitis

• Malaise

• ALL OF THESE MAY OCCUR BEFORE COUGH

• Chlamydia specific:

  • Persistent cough

Mycoplasma systemic s/s:

• Rash, SJS, Hemolytic anemia

• Joint/Liver/Pancreatic/Myocardial inflammation

Legionella S/s: has different s/s compared to the other atypical ones :o

• Respiratory:

  • Abrupt high fever

  • Productive cough, pleuritic chest pain

  • Issues breathing, invasive infection

• CNS:

  • Lethargy, altered LOC

• GI:

  • N/V, diarrhea, abd pain

• Other:

  • Headaches, v HR

  • Liver & Kidney issues

Viral pneumonia s/s:

Develops more gradually

• Follows URI

• Coryza, sore throat

• Wheezing

Pneumonia d/x:

Chest x-ray: GOLD-STANDARD

• May appear normal at first → repeat imaging after some days PRN

Sputum culture

Blood cultures: if hospitalized

PCR:

• If viral suspected

CBC → a/x WBCs; & BMP → regular labs & dehydration

CRP & ESR labs

• May be checked if hospitalized or in severe conditions

Atypical Pneumonia testing:

Serologic antibody testing

• Only limitation is that

  • antibodies take time to develop: early testing → false (-) r/x

    • “not enough Abs”

  • antibodies may also remain for long time → false (+) r/x

    • “Abs may reflect previous infection”

Pneumonia general t/x:

Supportive care:

• Hydration (PO or IV), fever management, resp support, pain control

• High-fowlers, NC if <95% or in resp distress

Bacterial & Atypical Pneumonia ABX:

If suspected → empiric ABX right away

• Depends on:

  • exposure, course, age, medical h/x, i/x organism, culture results

• Oral ABX can be as effective as IV therapy in severe scenarious if child can tolerate fluids but does not have suspected sepsis

GUIDE:

Organism	Medication
Staphylococcus aureus	Ampicillin or penicillin G
S. pneumoniae	Ampicillin/penicillin G if fully immunized
Severe/unimmunized <12 months	Cefotaxime or ceftriaxone
CA-MRSA	Clindamycin or vancomycin
CA-MRSA alternative	Ceftaroline
M. pneumoniae	Macrolide
C. pneumoniae	Macrolide
L. pneumophila	Macrolide
Older child/adolescent with atypical infection	Levofloxacin or moxifloxacin
C. trachomatis <6 months	Azithromycin

Viral pneumonia antiviral therapy:

Virus	Antiviral
Influenza	Oseltamivir
Herpes simplex	Acyclovir
Varicella	Acyclovir
CMV	Ganciclovir / CMV immunoglobulin
RSV	Ribavirin / nirsevimab as listed in source
Adenovirus	Cidofovir

If Influenza is suspected → Oseltamivir STAT

• Don’t wait till labs come, lock in

Neonatal pneumonia t/x:

Special attention to:

• O2, temp, glucose, Metabolic acidosis, hydration, & E+

• More prone to HYPOTHERMIA

  • Older children have more concerns for fever

Neonatal ABX therapy:

Early-onset:

• Ampicillin + gentamicin

• AVOID 3rd gene cephalasporines

Late-onset:

• Ampicillin OR Vanco + Aminoglycosides OR extended-spectrum cephalosporins

If cultures are (-) but still indicates infection → keep ABX therapy for + 48-72 hrs → if still concerning → continue t/x for 7-10 days

Special neonatal organism → t/x table:

Situation/Organism	Treatment
Hospital-acquired pneumonia	Vancomycin
Community-acquired with high MRSA rates	Nafcillin
Group B Streptococcus	Penicillin or ampicillin
E. coli	Ampicillin
Ampicillin-resistant E. coli	Cefotaxime, ceftazidime, or cefepime
Gram-negative organisms	Based on susceptibility
Multi-drug resistant organisms	Meropenem may be used
S. aureus	Nafcillin
S. aureus alternative	Cefazolin
MRSA	Vancomycin
C. trachomatis	Azithromycin

Guided via sensitivity report

What are children w/pneumonia at risk for developing later in life:

Asthmatic-type s/s:

• May require additional t/x

• Possible ^^^ stress

Pneumonia care strats + edu:

Hib + Pneumococcus + Influenza vaccine

Other strats:

• Proper hand hygiene + Strict infection-control procedures

• Avoid cigarette smoke exposure

• Avoid smoking

• Keep suctioning to prevent aspiration possibilities

• Teach older children/adolescents about smoking risks

• Healthy meals/snacks

• Adequate rest and sleep

• Maintain immunizations

Parent edu:

• Hydration, fever management, airway clearance (bulb, deep breathing, cough techs), pain control

• AVOID cough suppresents → worsens pneumonia due to impaired airway clearance

• make sure they return demonstrate!

What is influenza? Its Seasonal pattern?

Viral infection causing resp s/s

• Seasonal pattern:

  • Peaks late fall → continues in winter → v in early spring

  • May be different due to time of peak, type, & season duration

• C/x by influenza A or B → inhaled or picked up from surface

  • Highly infectious; resp droplets

• D/x: swab test

Hospitalization of Neonates vs Older children regarding the flu:

Neonates:

• Fever

Older children:

• resp s/s

• Sepsis

• Severe complications

Influenza r/x: and how to v r/x

<5 years; <2 years ^^^ r/x

• Infants: <6 months

• Underlying medical conditions

• Arican American, Hispanic, Indigenous, Asian americans

High r/x for severe disease:

• Underlying, immunocompromised, infants (<6 months)

• Death is rare tho

Lowering r/x:

• Vaccination = v severity & r/x

• Breastfeeding for first 6 months

Flu s/s; & A v B & complications

Depends on:

• Age, health, underlying conditions

• Previous infections, types

General: lasts for around 7 days; some s/s may happen after infectius period (maliase/lethargy) → several weeks (even when taking t/x meds)

• Fever, Malaise, Headache, Muscle Aches

• Rhinitis

May lead to:

• Pneumonia:

  • Especially if:

    • Underlying disease, immunocompromised, <2 yrs

• Exacerbations, Croup, ARDS, Plastic bronchitis

• SEPSIS:

  • Strep pneumoniae or Staph. aureus

  • May occur even with health patients

• Neuro:

  • Febrile seizures:

    • Fever management essential

  • Encephalitis

  • Reye syndrome

  • Guillian-Barre Syndrome

• Myositis (calves) → releases muscles enzymes → muscle breakdown → renal failure

• Myocarditis (chest pain, changes in rhythm)

Influenza A:

• More severe & prominent s/s

Flu d/x:

Influenza testing via Nasopharyngeal swabs

• More accurate → PCR

• Respiratory Pathogen Panel: helps establish a differential d/x

• CXR

  • Rules out pneumonia

Flu t/x:

Antiviral therapy

Oseltamivir	Oral; most commonly used
Zanamivir	Inhaled; use if no chronic respiratory disease
Baloxavir marboxil	Single oral dose; early uncomplicated influenza; ≥5 years
Peramivir	IV; approved for children ≥6 months

Supportive Care:

• Fever & Pain control

• Hydration

• resp & airway support

• Vaccination:

  • Starting 6 months

  • 2 part dose → yearly

• Regarding play:

  • clean objects as flu can stay in surface for up to 2 days

What is Acute Viral Nasopharyngitis?

Common cold of the nose & nasopharynx

• Virus infects in mucosal cells & replicates → dmgs tissue → inflammation → s/s

• Person-person contact; contaminated objects; droplet transmission

  • Wash hands, cough etiquetts, resp hygiene, isolation

• Rhinovirus, Adenovirus, common coronavirus, & influenza A & B

Acute Viral Nasopharyngitis r/x:

Children, Adolescents,frequent exposure to others

Season:

• Winter/Early spring

Acute Viral Nasopharyngitis s/s: Infants vs older children

Infants

• Fever, Rhinorrhea (viral)

• Poor feeding, fussiness, poor sleep

Older children:

• Sore throat, large lymph

• Cough (viral), conjuctivitis

• Head/earache

• Body aches, lethargy, fatigue

Usually no developmental impact delays

Acute Viral Nasopharyngitis D/x:

Based on:

• s/s, health h/x, report

• If unclear → GAS pharyngitis testing via throat swab

Acute Viral Nasopharyngitis t/x:

Comfort care:

• Relieve throat pain

  • Warm salt-water gargle

    • Mix 1/4-1/2 salt + 8z water

  • OTC pain meds tylenol/ibuprofen

  • Cold/warm fluids

  • Cold foods

    • Ice chips, popsicles

  • Coughdrops/Lozenges for Toddlers

    • maintain upright, dont run around, supervise

    • Usually not given

• Prevent dehydration

  • Encouraging methods:

    • Let child choose drink if okay, turn it into game

    • “tea party”

    • Offer variety, reward, cold/warm options

    • Honey IF >12 months

• AVOID SMOKE

• Humidifier, soft foods, avoid acidic/spicy food

What is Streptococcal pharyngitis?

Bacterial infection caused by (GAS) → pharynx inflammation & secretions

Streptococcal pharyngitis c/x & r/x

1/3 of all pharynx infections

• Less common in children <3years

R/x:

• Preschooler/early school age or school age chilren

• Age of 15 years

• Close contact w/other children in school

• Winter & Early spring

• Congregating indoors w/others

Streptococcal pharyngitis s/s & complications:

Sudden onset sore throat → severe throat pain + fever + bright red throat/pharynx w/petechia & white patchy exudate

• NO COUGH OR RUNNY NOSE ⭐

• Cervical lymphadenopathy too

• Strawberry tongue, scarlatina rash

May lead to:

• Rheumatic fever → heart/kidney/neuromuscular issues

Streptococcal pharyngitis D/x

GAS throat testing (swab) → if there is still suspicion → throat culture

Streptococcal pharyngitis t/x

ABX

• Take complete course

• Amoxicillin (Qdaily PO)

• If there is adherence concern RN, Penicillin IM is a possiblitiy

  • Alternative: Clindamycin

Pain + Fever management

Additional:

• Warm gargles, warm/cold drinks, desserts frozen

• Soft foods, hydration, X smoke, X acid/spicy foods

• May go play after 1-2 days of ABX t/x

What is Tonsililitis?

Tonsillitis causes by virus/bacteria; back of throat

• Connected to lymphatic

• May lead to:

  • Peritonsillar abscess: infection becomes trapped between pharyngeal constrictor muscles & tonsillar capsule → abscess → Airway compromise

Tonsililitis Major complications:

If c/x by GAS → rheumatic fever/heart disease + glomerulonephritis + Neuromuscular issues

Tonsililitis R/x:

5-15 yrs

• Rare in children <2

• Winter & Early spring

Tonsililitis D/x:

1. H/x:

• Ask when/how s/s appeared

• Progression

2. GAS Throat swab: done if bacterial suspected

3. If still suspected despite (-) → throat secretion culture

Tonsililitis T/x:

Viral: Supportive care

• Fluids, Cold liquids

• Pain meds, throat lozenges, rest

• Hand hygiene + etiquette + infection-control

Bacterial:

• Amoxicillin QDaily

• If nonadherence suspected → Penicillin IM

Tonsililitis; how to encourage drinking

Use fun drinking devices

• Silly straw

Turn drinking into game/competition

Give child choices of beverages

Tonsililitis throat reflief interventions:

Warm salt-water gargles

Warm/Cold beverages

Frozen drinks/desserts

Tonsililitis, when to return to daycare?

GAS tonsilitis: after 1 day of t/x

Viral tonsilitis: return depends on

• How communicable virus is

• S/s, recommendations

What does recurrent tonsillitis usually require?

Tonsil removal surgery

• Include:

  • Child-life specialist

  • Atraumatic care

Tonsilitis, when appropriate to play:

Bacterial: 1-2 days of ABX t/x

Viral: self-limiting → improves within several days

Types:

• TV, reading, puzzles

Pertussis:

Highly communicable resp infection (Bordetella pertussis) → dmgs cillia that clears mucus from airway → thick mucus + airway inflammation + poor secretion clearance → severe coughing episodes/spells

• Can lead to:

  • Severe respiratory illness

  • Death in infants, immunocompromised, & young children

• Standard + Droplet precautions

  • Limit visitors 5 days after starting therapy

  • If child leaves room, place surgical mask on them

• Incubation period: 4-21 days

• Contagious period: 2 weeks after cough appears

• Lasts 6 weeks on average

Pertussis transmission:

Breathing very close to an infected person

Sneezing/Coughing
Contaminated surface

MANDATORY REPORTABLE DISEASE

Pertussis r/x:

Under/nonimmunized

Infants, Immunocomrpomised

Poor SDOH, crowded housing, refugee status

Pertussis s/s:

Stage 1: Catarrhal Stage

• Intermittent mild cough; low-grade temperature

Stage 2: Paroxysmal Stage

• Thick mucus + dmged cells → unable to clear secretion

• Coughing spells: rapid & violent coughs

  • More prominent at night

• Inspiratory effort → high pitched “whoop”

• Vomiting → Poor oral intake → dehydrated

• Cyanosis

• Capillary Rupture

  • Facial bruising, petechiae

  • Eyes too

• Chest pain or Broken ribs

Stage 3: Convalescent Stage

• v frequency → resolve

• Takes 3 weeks to reach this stage