AMBULATORY PEDIATRICS

Asthma - Pathophysiology

- Chronic reversible airway obstruction, inflammation, and bronchial hyperresponsiveness

Asthma - Risk Factors

- Family history

- Hx of atopy and allergies → hypersensitivity characterized by excessive IgE

- Prematurity

- Tobacco exposure

Asthma - Acute Findings

- Tachypnea + tachycardia

- Retractions → visible sinking in the skin around ribs, neck, and collarbone

- Prolonged expiration + decreased air entry

- Expiratory wheeze

Signs of Atopy in Asthma

- Atopic dermatitis

- Dennie lines → creases under eyes

- Allergic shiner → bruise marks around the eyes

- Conjunctival erythema

Asthma - Diagnosis

- Do PFTs in kids ≥ 5 years old

- CXR only to rule out other causes → shows increased lung volumes + hyperexpansion + diffuse atelectasis

Asthma - Treatment

- Rescue: SABA → quick relief from symptoms and for prevention during exercise

- Controller: ICS → most effective tx for chronic asthma -> Daily use affects linear growth → use lowest dose possible

- LABA → used in moderate-severe asthma when ICS alone can't control it -> DON'T USE AS MONOTHERAPY

- Leukotriene receptor antagonists (LTRA) → mild persistent asthma or add-on to ICS

Criteria for Intermittent Asthma in Kids

- Daytime S/S ≤ 2 days/week

- No nocturnal awakenings

- No interference with activities

- 0-1 exacerbations treated with PO glucocorticoids per year and no risk factors for exacerbations

Tx for Intermittent Asthma in Kids < 4 yo

- Reliever therapy = SABA as needed

- Controller (Preferred) = Short course of medium dose ICS

Criteria for Mild Asthma in Kids

- Daytime asthma symptoms 3-6 days per week

- 1-2 nocturnal awakenings per months due to asthma

- Minimal interference with normal activities

- 2 or more exacerbations requiring oral glucocorticoids per year or ≥ 4 episodes of wheezing lasting more than a day in year + risk factors for persistent asthma

Tx for Mild Asthma in Kids < 4 yo

- Reliever therapy = SABA as needed

- Controller therapy (preferred) = Daily low dose ICS

- Controller therapy (alternative) = Intermittent low dose ICS used whenever a SABA is used OR Daily LTRA

Criteria for Moderate Asthma in Kids

- Daily symptoms of asthma

- 3-4 nocturnal awakenings per months

- Occasional limitation in normal activity

- 2 or more exacerbations requiring oral glucocorticoids in 6 months

Tx for Moderate Asthma in Kids < 4 yo

- Reliever therapy = SABA as needed

- Controller therapy (preferred) = Daily medium dose ICS OR Daily low dose ICS-LABA

- Controller therapy (alternative) = Daily low dose ICS + LTRA

Criteria for Severe Asthma in Kids

- Asthma symptoms throughout the day

- Nocturnal awakenings more than once a week

- Frequent limitation in normal activity due to asthma symptoms

Tx for Severe Asthma in Kids < 4 yo

- Reliever therapy = SABA as needed

- Controller therapy (preferred) = Daily high dose ICS OR Daily medium dose ICS-LABA

- Controller therapy (alternative) = Daily medium dose ICS + LTRA

Reliever Tx for intermittent + mild asthma in kids > 4 yo

- SABA as needed

Controller tx for intermittent asthma in kids > 4 yo

- Low dose ICS whenever SABA is used

Controller tx for mild asthma in kids > 4 yo

- Preferred = Daily low dose ICS

- Alternative = Low dose ICS whenever SABA is used OR Daily LTRA

Reliever tx for moderate asthma in kids > 4 yo

- Low dose ICS (formoterol → fastest LABA) + controller therapy as needed OR

- SABA as needed with alternative controller therapy

Controller tx for moderate asthma in kids > 4 yo

- Preferred = Daily low dose ICS (formoterol) as needed

- Alternative = Daily low dose ICS- LABA (not formoterol) OR Daily medium dose ICS OR Daily low dose ICS + LTRA

Reliever tx for severe asthma in kids > 4 yo

- Medium dose ICS (formoterol) as needed + daily controller therapy OR

- SABA as needed with alternative controller therapy

Controller tx for severe asthma in kids > 4 yo

- Preferred = Daily medium dose ICS-LABA

- Alternative = Daily medium dose ICS-LABA OR Daily high dose ICS OR Daily medium dose ICS + LTRA OR Daily medium dose ICS-LABA + tiotropium or LTRA

Viral URI

- Invasion of virus into the inner lining of the upper airway (MC at nasopharynx)

- Etiology: Rhinovirus (MC), adenovirus, parainfluenza

- Diagnostics: Clinical, but can use a respiratory viral panel in some instances

S/S of viral URI

- Rhinorrhea

- Fever

- Cough

- Mouth breathing + scratchy cough

Tx for viral URI

- Supportive only → tylenol/motrin for fever + pain

- OTC decongestants + cough suppressants → not FDA approved for kids < 4 yo (use sparingly)

- Increased fluids

- NO antibiotics

Acute Otitis Media (AOM) - Pathology

- Normal → patent but collapsible eustachian tube allows fluid drainage into middle ear into the nasopharynx but prevents retrograde entry of upper respiratory flora

- Pathology → in kids, shortened length + angle of entry + decreased tone of tube increases susceptibility of retrograde bacterial entry

- When pt is sick, tube narrows → bacteria backs up into the middle ear → infx

Acute Otitis Media (AOM) - Risk Age and Pathogens

- MC in kids 6-24 months old

- Pathogens: S. pneumoniae; Moraxella; H. influenzae

- Viral → RSV, flu, hMPV, coronavirus, adenovirus

Acute Otitis Media (AOM) - Findings

- Bulging, erythematous TM

- Fever + fussiness + poor feeding

- Decreased mobility

- Ear pain with ear rubbing in infants

Acute Otitis Media (AOM) - Differential Diagnosis

- Otitis media w effusion → fluid behind TM w/o inflammation -> Gray/translucent TM + no fever + no ear pain

- Myringitis → inflammation of TM with normal ear mobility

- Otitis externa → inflammation of ear canal (causes ear pain but normal TM

Acute Otitis Media (AOM) - Diagnosis

- DX: TM bulging + opaque + erythematous + decreased light reflex + pneumatic otoscopy with decreased mobility

Acute Otitis Media (AOM) - Tx

- High-dose amoxicillin x 10 days

- Recurrent (within the last month) → amoxicillin-clavulanate

- PCN allergy → 2nd or 3rd gen cephalosporins

- 2nd gen → cefuroxime + cefoxitin

- 3rd gen → ceftriaxone + ceftazidime

Chronic Otitis Media

- Leading cause of hearing impairment in environments with lack of access to care

- Chronic drainage from middle ear associated with TM perforation >6 weeks

- Usually precedes acute otitis media

Tx for chronic otitis media

- Aural toilet → clears debris + exudate

- Topical ofloxacin or ciprofloxacin drops

Otitis Externa (Swimmer's Ear)

- Pathology: Inflammation/infection of external auditory canal or auricle or both

- Acute bacterial infection of the skin of the ear canal

- Caused by absence of cerumen + high humidity + retained water in ear canal + increased temperature + ear trauma

- Pathogens: Pseudomonas + Staph aureus

Hallmark of Otitis Externa

- Hallmark: Pain with tragus manipulation or traction to the pinna

S/S of otitis externa

- Edematous external auditory canal

Tx for otitis externa

- Hydrocortisone + neomycin + polymyxin B otic drops

- Ciprofloxacin + hydrocortisone

- Dexamethasone otic drops

Sinusitis

- Infection/inflammation of mucosal lining or 1 or more of the paranasal sinuses

- Etiology: Same as otitis media

- MCC → rhinovirus + SMH

Sinusitis - Diagnostic Criteria

- URI symptoms >10-14 days OR High fever + purulent discharge ≥3 days OR Worsening URI s/s

- Dx: Clinical but do CT when there is poor response to tx

Sinusitis treatment

- Same as AOM → 10-14 days

- High-dose amoxicillin x 10 days

- Recurrent (within the last month) → amoxicillin-clavulanate

- PCN allergy → 2nd or 3rd gen cephalosporins

- 2nd gen → cefuroxime + cefoxitin

- 3rd gen → ceftriaxone + ceftazidime

S/S of viral rhinosinusitis

- Fever = Typically absent. When present → low grade and usually only in the 1st 24 hours + Resolves within 1st 2 days

- Nasal discharge + cough = Peaks on day 3-6 then improves

- Ill appearance + Severe HA = ABSENT

- Clinical course = Symptoms peak in severity on days 3-6 and then improve

S/S of bacterial rhinosinusitis

- Fever = ≥39 C (102.2 F) for > 3 days + can redevelop on day 6-7 after initial improvement

- Nasal discharge + Cough = Fails to improve substantially or worsens over time

- Ill appearance = May occur in severe cases

- Severe HA = Maybe a sign of severe illness or complication

- Clinical course = Symptoms present for ≥ 10 days WITHOUT improvement

Croup (Laryngotracheobronchitis) etiology

- Etiology: Parainfluenza 1, 2, and 3 - Can also be caused by RSV - Peak incidence during the wintertime

Croup (Laryngotracheobronchitis) pathology

- Pathology: Viral induced inflammation of laryngotracheal tissues causing airway obstruction

- Common ages = 6 months-5 years

Croup (Laryngotracheobronchitis) findings

- Prodromal URI → low grade fever + rhinorrhea

- Barking cough

- Inspiratory stridor

- Steeple sign (CXR) → narrowing of subglottic area in the pharynx

Croup (Laryngotracheobronchitis) treatment

- Cool humidified mist + hydration

- Dexamethasone IM or PO

- Nebulized racemic epinephrine

Strep Pharyngitis etiology

- Group A B-hemolytic Strep (GAS; S. pyogenes)

- MC affects school aged kids

- Spread via infected oral secretions

Strep Pharyngitis pathology

- Strep adheres to pharyngeal mucosa + invades tissue causing inflammation

Strep Pharyngitis findings

- Fever

- Sore throat

- HA

- Malaise

- Nausea

- Abdominal pain → think strep

- Enlarged exudative tonsils

- Tender cervical LAD

- No cough

Strep Pharyngitis diagnosis

- Rapid antigen + throat culture

Strep Pharyngitis treatment

- Penicillin or amoxicillin x 10 days

- PCN allergy: Cephalexin + cefadroxil + clindamycin + azithromycin + clarithromycin

Gastroenteritis pathology

- Invasion of intestinal tissue or secretion of toxins leading to intestinal inflammation

- Viral (MC): Norovirus + Rotavirus

- Bacterial: Salmonella + Shigella + E. coli

- Parasite: Giardiasis

Gastroenteritis S/S

- Diarrhea + vomiting + abdominal pain + poor PO intake + fever

Gastroenteritis Dx

- Electrolyte + renal function study

- Blood culture if bacterial GE suspected

- Stool culture for O&P

- C. diff toxin screen

Gastroenteritis Tx

- Manage dehydration

- Supportive for viral

- Antibiotics if bacterial (case dependent)

Urinary Tract Infection pathology

- Acute inflammation of bladder (may include pyelonephritis)

- Causes discomfort upon contraction during voiding

Urinary Tract Infection pathogens

- E. coli (MCC) - Others → proteus + klebsiella

Urinary Tract Infection S/S

- Dysuria + Fever + Polyuria → increased urine output

- Hematuria

- Enuresis → involuntary voiding during sleep

- Pyelonephritis → high fever + chills + nausea + vomiting + flank pain

Urinary Tract Infection dx

- UA + Urine culture

- May have to straight catheterize for sterile sample

Urinary Tract Infection imaging

- <24 months → renal US

- Hydronephrosis/unresponsive to tx → voiding cystourethrogram

Urinary Tract Infection tx

- Nonfebrile = Cephalexin PO x 5 days

- Febrile = Cefixime PO x 14 days or cefixime IV x 3 days

- Allergy: TMP-SMX or Nitrofurantoin or Augmentin

Diaper Dermatitis pathology

- MCC → leaving wet diaper on for too long

- Form of irritant contact dermatitis from urine or feces or both

- Involves perianal region + buttocks

- Irritant contact dermatitis spares groin folds

- Candida involves folds

Irritant contact dermatitis vs candida diaper dermatitis

- Irritant contact dermatitis spares the groin folds

- Candida involves the groin folds

Diaper dermatitis tx

- Change diapers frequently + expose skin to air when feasible

- Barrier ointment → oil based (vaseline)

- Nystatin cream/powder if fungal

- Zinc oxide cream

Epistaxis pathology

- Bleeding when nasal mucosa is eroded + vessels become exposed and subsequently break

- Usually in winter month's

- Associated with nose picking

- MC Source: 90% of cases are anterior septal bleeds → Little's area where Kiesselbach plexus forms on the septum

Epistaxis etiology

- Local causes → trauma + mucosal irritation + septal abnormalities + inflammatory diseases + tumors

- Systemic causes → blood dyscrasias (thrombocytopenias) + chemical toxicities + allergic rhinitis

- Trauma (MC)

- Dry air

- Coagulopathy

Epistaxis treatment

- Manual hemostasis (direct pressure) + moisturization or nasal saline sprays

- Oxymetazoline (Affrin)

- Silver nitrate or electrocauterization cautery

- Nasal packing

Anaphylaxis - Mechanism

- Type 1 IgE-mediated mast cell degranulation → release of histamines + other mediators

- Requires previous exposure to specific antigen → production of antigen specific immunoglobulin (IgE)

- Anaphylaxis occurs on the 2nd or 3th exposure to antigen

- Can be caused by food + drugs + insect stings → can be within minutes up to 1 hr after exposure

Anaphylaxis - Uniphasic vs Biphasic vs Protracted

- Uniphasic (MC) → lasts 1-2 hrs and resolves w tx

- Biphasic → relapse occurs hours to days -> Increased risk w food allergies + pts receiving more than 1 dose of epi or delay in initial treatment

- Protracted → lasts days despite aggressive tx

Anaphylaxis - Symptoms

- Tachycardia + tachypnea + diaphoresis

- Hypotension (late finding)

- Wheeze/stridor

- Urticaria

- Retraction + flaring of nostrils

- Angioedema of lips + tongue + periorbital region

- Warm extremities with bounding pulses

Anaphylaxis - Treatment

- IMMEDIATE Removal of trigger → stop IV if drug induced

- IM epinephrine 0.01 mg/kg (max 0.5 mg) in mid-outer thigh

- IV fluids

- Oxygen

- Adjunct: Antihistamines → histamines + Steroids (methylprednisolone) + Albuterol

Allergic Rhinitis pathology

- 2 step process

- Sensitization → antibody induction stage

- Mediator release upon reexposure

Allergic Rhinitis etiology

- Exposure to allergen → dust + pollen + etc

- Bimodal distribution → early childhood then early adulthood

Allergic Rhinitis symptoms

- Chronic clear rhinorrhea

- Nasal congestion + postnasal drip

- Conjunctival tearing and injection + pruritus

- Wheezing + mouth breathing + snoring

- Chronic cough

- Itchy eyes

- Seasonal pattern

- Atopic dermatitis or urticaria

Allergic Rhinitis dx

- Skin prick testing

- Intradermal allergy testing is skin prick is negative but still concerned for allergy

Allergic Rhinitis tx

- Avoidance of allergen

- H1 receptor antagonist → 2nd generation has less drowsiness

- Intranasal steroids (first-line for allergic rhinitis) → fluticasone propionate + mometasone furoate

- Immunotherapy

- Systemic steroids for urticaria + angioedema + anaphylaxis

- Allergic conjunctivitis → ophthalmic antihistamines + mast cell stabilizers + vasoconstrictors

Pinworms

- Organism: Enterobius vermicularis

- Etiology: MC in preschool + school aged kids

- Symptom: Perianal itching (night)

- Diagnosis: Tape test examined under low power microscope

- Treatment: Pyrantel pamoate or Albendazole

- Good handwashing to prevent pinworm infection