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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

Wright, 2016 2

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


Development & Anticipatory Guidance

• Anticipatory Guidance–Every visit from birth – age 21

–Specific guidance is based upon age

4Wright, 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

Wright, 2016 6

https://pediatriccare.solutions.aap.org/DocumentLibrary/Periodicity%20Schedule_FINAL.pdfaccessed 06-10-2015

2

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

Wright, 2016 7


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/

Wright, 2016 11

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.

Wright, 2016 12

http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011

3

Lead Screening

• AAP recommendations– 12 months or…

– 24 months

• Continued risk factor assessment throughout childhood

13Wright, 2016

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

Wright, 2016

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

15

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

Wright, 2016 16

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

18

Remember –School / sport physicals may be the only contact that the child has with a health

care professional in a yearWright, 2016

4

Depression Screening

• AAP recommends depression screening for all adolescents11-21 years of age

• Validated depression screening tool recommended– PHQ-2 or PHQ-9

Wright, 2016 19


Vaccine Updates 2016

Wright, 2016 20

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.

Wright, 2016 22

Updated ACIP Recommendations

Why Change the Program Now?

• Data indicates protection wanes within 5 years after vaccination

Wright, 2016 23

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

Wright, 2016 24

5

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

Wright, 2016 25

Influenza

Wright, 2016 26

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

Wright, 2016 27

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

6

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

Wright, 2016 32

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

7

Eyes

Wright, 2016 37

Clinical Pearl:

Document visual acuity on all eye

complaints

38Wright, 2016

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

39Wright, 2016

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

40Wright, 2016

Hordeolum

41Wright, 2016

Internal Hordeola

42Wright, 2016

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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

45Wright, 2016

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

48Wright, 2016

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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

53Wright, 2016

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

54Wright, 2016

10

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

Wright, 2016 56

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)

Wright, 201657

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)


Hyphema

Wright, 201660

11

Complication of Hyphema

Wright, 201661

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


Herpes Simplex

Wright, 201663

Corneal Ulcer

Wright, 201664

Nose/Sinuses

Wright, 2016 65

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis

in Children and AdultsClinical Infectious Diseases Advance

Access published March 20, 2012

Wright, 2016 66

http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012

12

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].

Wright, 2016 67

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

Wright, 2016 68


Wright, 2016 69

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

Wright, 2016 70

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

Wright, 2016 71

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

13

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


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


When to Refer

Wright, 2016 76http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012

Ear Conditions

77Wright, 2016 Wright, 2016 78

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Variations of Tympanic MembraneNormal TM

Acute OM

Otitis Media with Effusion

79Wright, 2016

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

Wright, 2016 80

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)

Wright, 2016 81


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

Wright, 2016 82


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

Wright, 2016 83


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


15

Summary: AAP Updated Guidelines (cont.)

Wright, 2016 85


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


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


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

Wright, 2016 88


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

Wright, 2016 89


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


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

102Wright, 2016

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


• Physical examination– May appear restless

– Irritable

– May lie with head hyperextended to facilitate respirations

– Muffled voice

– Stridor may be present

– Respiratory distress

111Wright, 2016


• Physical examination findings–Fiery red asymmetric swelling of

one tonsil

–Uvula is often displaced contralaterally and often forward

–Large, tender lymphadenopathy

112Wright, 2016


113Wright, 2016


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)


(and asthma is well-controlled at

least 3 months)


(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


LABA


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


LABA + Oral Systemic Corticosteroid


either LTRA orTheophylline

+

Oral Systemic Corticosteroid

Step 6


LABA + Oral Systemic Corticosteroid


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


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)


(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


• 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


• 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


• 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


• 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


• 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


• 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

Wright, 2016293

Summer 2009

Wright, 2016 294

50


• Signs– Systemic symptoms

• Facial palsy

• Meningitis

• Carditis

Wright, 2016 295


• 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


• 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

51

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

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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

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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


• Plan– Educational

• May resolve on own in 6 - 9 months

• Contagious until lesions are gone

• Benign

• Recurrence very common

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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

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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

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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

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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

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Scabies

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Scabies

•

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Scabies

• Diagnosis–Scraping to look for mite, eggs or

feces

• Plan–Diagnostic: Scraping–Therapeutic

• Permethrin 5% cream

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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


• 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

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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.

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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.

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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

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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

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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

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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

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Atopic Dermatitis

• Signs–Pruritic, erythematous dry patches

–Cracking and fissuring

–Lichenification (Thickening of the skin)

–Excoriations (Caused by scratching)

–Diffuse borders (different than psoriasis)

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Diagnosis?

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331

Common Locations

• Infants: scalp, face, and extensors

• Children: neck, flexor folds, feet

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Atopic Dermatitis

• Plan–Diagnostic

• None

–Therapeutic• Lubrication: Most important part

• Perform multiple times daily; particularly after a bath

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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

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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

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Diagnosis?

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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

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• 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

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• 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

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Chicken Pox

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• Plan– Diagnosis: None

– Therapeutic: Symptomatic Treatment

• NO ASPIRIN

• Clip Nails

• Caladryl or Benadryl

• Antiviral

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• 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

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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

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Tinea Corporis

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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

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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

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• Symptoms

–Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling

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• 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

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Herpetic Gingivostomatitis

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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)

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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

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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


Roseola

• Treatment–Ibuprofen

–Acetaminophen

–Tepid baths• Cautiously with

fever


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


• 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


• 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

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Fifth’s Disease

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• 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

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• 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

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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

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62


• 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


• 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

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Hand Foot and Mouth Disease

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Hand Foot and Mouth Disease

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• Plan–Diagnostic: None

–Therapeutic• Tylenol

• Warm baths

• Oragel or diphenhydramine/Maalox

• Magic mouthwash371Wright, 2016


• Plan– Educational

• Very contagious (2d before -2 days after eruption begins)

• Entire illness usually lasts from 2 days – 1 week

• Reassurance

• No scarring

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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


• 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


• Physical Examination Findings– Tender

– Bullae with purulent center which ruptures quickly

– Black eschar appears and the pain decreases

– Systemic symptoms begin

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64


Bullae: Below these lesions is necrotic tissueWright, 2016 379


• Plan

–Diagnosis: Culture of wounds, blood cultures, biopsy of area, CBC with differential, urinalysis

–Therapeutic: HOSPITAL ADMISSION

–Educational: Good wound hygiene

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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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• 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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65

Erythema Multiforme

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• 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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389

Thank you for your time and attention!

For further programming, please visit us at:

www.4healtheducation.com

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